Post-Acute Nominations Hall of Fame Nomination Form - Post Acute Please fill out the form below to submit information about your Hall Of Fame Inductees. For more information please contact: Anna Bass-Wilson Quality of Life Director (502) 804-3794 firstname.lastname@example.org Submitter's Name* First Last Submitter's Email* Inductee Name* Facility Name*Input the name of your facility. Example: "Signature HealthCARE of South Louisville"Inductee is a:*StakeholderResidentCommunity LeaderInductee Categories: Recognition will be based on contribution made in the following categories:*(Please select the most appropriate option, limit two) Academia Community Involvement Distinguished Military Service Entrepreneur Founder Journalism Leadership Personal Accomplishments Professional Accomplishments Public Service Sports Theater / Arts / Entertainment Volunteerism Writer / Author / Poet Inductee Highlights* (Three short bullet points of their life that distinguish the inductee) Biography of Inductee*(Please type in the text box the biography of the inductee, three to four short paragraphs)Upload Nominee Photo Drop files here or Accepted file types: jpg, jpeg, png, pdf, doc, docx, avi. Upload a photo of the Hall of Fame nominee. Please check that there is a media release form on file. This iframe contains the logic required to handle Ajax powered Gravity Forms.