Society of Health and Physical Education- Michigan - SHAPE

* Email

* Name of person making nomination:

* Address of person making nomination:

* Name of Nominee:

* Nominee's E-mail:

* Nominee's Home Address:

* Nominee's Phone Number:

* Is the nominee a member of SHAPE-MI?

Yes
No

Is the nominee active or retired from an allied health/physical education profession (examples listed in criteria)

Yes
No

* How has the nominee contributed to the allied professional disciplines through any or all of the activities listed in the criteria?

* Please cite examples of professional service that the nominee has provided in support of healthy, active lifestyles in Michigan.

* What grants or other educational awards has the nominee received?

* Upload a current picture or headshot of nominee:

* Please upload three letter of support (one these may be the letter of nomination)

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SHAPE - MI: Meritorious Service Award