Pediatric Nurses Week 2024 Nomination Form

Pediatric Nurses Week is October 7-11! Celebrate and honor a pediatric nurse who has made an impact on your family and nominate them below! Nominees will receive Beads of Courage Rose Quartz Stepping Stone Pendant.

Name of adult submitting nomination Name of adult submitting nomination First Last
Email
(BOC Family/Person making nomination) Mailing Address - Street Address (BOC Family/Person making nomination) Mailing Address - Street Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Where would you like the nomination gift to be mailed?

Where would you like the nomination gift to be mailed? I would like it shipped to me so I can gift them to my clinician Please ship it directly to my nominated clinician
Are you a BOC member family or a clinician nominating a colleague?

Are you a BOC member family or a clinician nominating a colleague? BOC Member Family Clincian
Name of BOC member/clinician if not the same as person filling out this form Name of BOC member/clinician if not the same as person filling out this form First Last
Name of nurse you are nominating Name of nurse you are nominating First Last
Organization where the nominee works (PLEASE BE AS SPECIFIC AS POSSIBLE)
Nominee's email address (if known)
If you want us to ship to the nurse you nominated - please include their mailing address: If you want us to ship to the nurse you nominated - please include their mailing address:
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please tell us why you are nominating the person named above
PHOTO Submission - Optional
Optional- Please share a photo we can share with your nominee and the public to honor them (can also email to abby@beadsofcourage.org)

Attach Files
Optional: Please describe the photos/videos you uploaded, include the names of those pictured:
Was the photo taken by a commercial photographer?

Was the photo taken by a commercial photographer? Yes No
I hereby give Beads of Courage, Inc. permission to use this photo/video and content I have provided, in perpetuity, for any purpose deemed appropriate by Beads of Courage, Inc., including but not limited to: print materials; newsletters; signage; on the Beads of Courage website and social media accounts; for media coverage (television, blogs, newspaper, magazine, ezine, ebook, etc.); for educational purposes; for publicity benefiting Beads of Courage, Inc.

I hereby give Beads of Courage, Inc. permission to use this photo/video and content I have provided, in perpetuity, for any purpose deemed appropriate by Beads of Courage, Inc., including but not limited to: print materials; newsletters; signage; on the Beads of Courage website and social media accounts; for media coverage (television, blogs, newspaper, magazine, ezine, ebook, etc.); for educational purposes; for publicity benefiting Beads of Courage, Inc. Yes - I give permission No - I do not give permisson I did not submit a photo
Date of Photo Release (if photo submitted) Date of Photo Release (if photo submitted) / MM / DD YYYY
ELECTRONIC SIGNATURE: By placing your signature in the box below, you are hereby waiving any right of compensation or ownership thereto.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.

Pediatric Nurses Week 2024 Nomination Form

Pediatric Nurses Week 2024 Nomination Form

PHOTO Submission - Optional