The Governor's Fitness and Health Leadership Award Nomination Form

Please complete and return to the Governor's Council on Physical Fitness and Health, PO Box 809, Jefferson City, MO 65102

1. Name of nominee (individual, business, organization or group):

   ___________________________________________________________________________

2. Contact person if school, business, organization or group: __________________________

3. Contact person's address: ____________________________________________________

4. Nominee's address: __________________________________________________________

5. Contact person's telephone number: (_______) ___________________________________

6. Nominee's telephone number: (_______) _________________________________________

7. Award category:
    ______ Individual   ______ Organization/Group
    ______ School      ______ Business/Industry/Government Agency

8. Please attach information describing the overall goals and objectives of the activity/program. Indicate the following:
   a. Population directly affected.
   b. Length of time involved in project or program.
   c. If a specific activity, will it continue on a long term basis or does the project have a specific completion date?
   d. Additional reasons why this individual or organization should be selected.

Please enclose any additional information which details the achievements and contributions of the nominee, including measurable results, audiovisuals and program materials. Submitted materials may not be returned.