Fields marked with * are required.


Humanitarian Award

Nominator Information

Nominator First Name* *
Nominator Last Name *
Nominator Degree *
Nominator Institution *
Nominator State *
Nominator Country *
Nominator Phone *
Nominator Email *

Nominee Information

Nominee First Name *
Nominee Last Name *
Nominee Degree
Nominee Institution
Nominee Department
Nominee State
Nominee Country
Nominee Phone
Nominee Email


Statement or letter describing the nominee's service and advocacy to mental illness. *