Nomination Form

* Required fields
Tell us about yourself
Your Name *
Organization/School
Address *
Phone *
	Daytime Evening
Fax
Email Address *
Tell us about your nominee
Name of Nominee *
Organization/School
Address *
Phone *
	Daytime Evening
Fax
Email Address *
Category *
Child (ages 6-12)	Youth (ages 13-17)
Family	Adult
Senior citizen	Group/Organization
School
Please answer the following:
1. What does your nominee do for regular physical activity? *
2. Why do you want to nominate your motivator in motion? *
3. What effect does physical activity have on your nominee and the lives of others? *
4. If any, what barriers or obstacles did your nominee overcome?

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