Community Oral Health Champion nomination form

Community Oral Health ChampionNomination form

Community Oral Health Champion nomination form

Nominee details Your details (if applicable)

Name Click here to enter text. Name Click here to enter text.

Organisation Click here to enter text. Address Click here to enter text.

Phone Click here to enter text. Phone Click here to enter text.

Email Click here to enter text. Email Click here to enter text.

In 500 words or less, outline how your nominee’s efforts have helped promote oral health or better public dental services in their community.

The judging panel will take into account the following considerations in reaching their decision:

How the nominee has shown excellence in oral health promotion in the community How the nominee has encouraged and supported access to public dental services for

eligible people in the community How the nominees work to promote and support the public oral health sector goes

above and beyond their usual duties or responsibilities

Terms and conditions of the awards can be found on www.dhsv.org.au/awards.

Click here to enter text.

Please remember to attach any supporting documentation to your nomination upon submission.

Send your completed nomination to awards@dhsv.org.au or submit an online nomination. Nominations close on September 25.

Winners will be announced at the 2015 DHSV AGM on November 26.