Award Nomination Form
You can use this form to nominate someone for the Public Health Champion or the Tū Rangatira mō te Ora Award. Please ensure you have their permission to place the nomination and provide personal details.

By completing this nomination form, you agree that the information provided can be used by Public Health Association marketing and media, in promoting the Public Health Champion and Tū Rangatira mō te Ora Award and the Public Health Association.

Which award would you like your nominee considered for?
Nominee Details
Please tell us who you are nominating for an award. Hint: Please type where it says "Your answer".
Nominee's name
Your answer
Nominee's email address
Your answer
Nominee's phone number
Your answer
Why are you nominating this person?
(max 400 words)
Your answer
Please confirm the nominee has agreed to being considered for the Public Health Champion or Tū Rangatira mō te Ora award.
Your Details
Your name
Your answer
Your email address
Your answer
Your phone number
Your answer
PHA Branch
If you are a member of a PHA Branch, please tell us which one. If you're not a member please skip this question.
Your answer
Additional details
Is there anything else you want to tell us?
Your answer
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