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WHI Community Ambassador Nomination Form
Dear WHI Member,
Thank you for your interest in nominating a person from your community to participate in the WHI Steering Committee by serving as a Community Ambassador.
Please complete and submit the form below. Any questions about the form or position can be answered by Deana Smith at
dgrabel@med.umich.edu
.
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Your Name:
Your answer
Please provide your contact information (email or phone):
Your answer
What is your role in the WHI (i.e. a community member, a representative from a health system, community organization, etc)? If you represent an organization, please specify.
Your answer
Name of person you are nominating:
Your answer
Please provide contact information for the person you are nominating (email or phone):
Your answer
How do you know the person you are nominating?
Your answer
Briefly share (2-3 sentences) why you think this person would be a good fit for the WHI. What insight or lived experience would they bring to the table?
Your answer
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