Nominee Information (Note: Please fill out as completely as possible. If you do not have contact information, we would appreciate any leads you can provide on how to contact this person.)

Name  _________________________________________________________________________

Age (if under 18) __________________________________________________________________

Business or organization (if applicable) __________________________________________________

Address _________________________________________________________________________

City _________________________  State _________________   Zip  ________________________

Phone (Day) ___________________ (Evening) ___________________ (Other) _________________

Fax _________________________  Email  __________________________________________

Leads to contact this person if above information is not available ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

Date and Location of heroic act:  _______________________________________________________

 Please describe clearly, and in as much detail as possible, the incident that occurred, and why you would like to see this person (or group of people) honored for their heroic act. Feel free to attach any supporting information.

 All statements will be reviewed by the Community HEROES selection committee. Each nominee will be notified to verify facts surrounding the event. Please tell us if you wish to remain anonymous.

 Event details:

________________________________________________________________________________

________________________________________________________________________________

_______________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

________________________________________________________________________________

Date submitted: __________________________

For information, or to learn more about the March, 2011 Community HEROES Dinner, please call

330-264-9383. Please mail nomination forms to:

                                                                   Community HEROES

American Red Cross

Wayne County Chapter

244 West South Street

Wooster, Ohio  44691

Nomination forms may be faxed to:  330-263-7794