USLA Heroic Acts Nomination Form - United States Lifesaving Association

USLA Heroic Acts Nomination Form

This form allows the nomination of persons, groups, and agencies for recognition of heroic actions. You are asked to complete the form in full and provide links to any media or other reports of the incident. You may also upload files (such as scanned media reports) as part of the nomination.

Before you start the nomination, please review our Heroic Acts Policy. This will help you determine if the actions of person(s) you wish to nominate meet USLA criteria. As well, you will be asked what category of award you consider appropriate. Definitions of categories are found in the policy.

If you have questions about the process, please email: heroicacts@usla.org

Name of Nominee *
Is Nominee a Lifeguard? *Is the nominee a professional, open water lifeguard?	Yes No	Is Nominee a USLA Member? *	Yes No Don't Know
If a USLA Member, Region?If the nominee is a USLA member, in what USLA Region is the nominee a member?
If a USLA Member, Chapter?If the nominee is a USLA member, of what chapter is the nominee a member?
If a Lifeguard, Agency?If the nominee is a lifeguard, what is the name of the lifeguard's employing agency?
If Non-Lifeguard, Occupation?If the nominee is not a lifeguard, what is the nominee's occupation?
If Non-Lifeguard Any Training?If the nominee is not a lifeguard, had the nominee received any prior training in rescue?	Yes No Don't Know
If Yes to Above, DescribeIf the nominee had received rescue training prior to the incident, please describe briefly.
Nominee's Email Address *
Nominee's Street Address *
Nominee's City *
Nominee's State/Territory *		Nominee's Zip/Postal Code *
Date of Action *
Time of Action		AM/PM	AM PM
Proposed Award *Select one category of nomination. (Heroic Act Committee may determine another category is most appropriate. This is your recommendation.) Refer to www.usla.org/heroicpolicy for details.
Incident Scene *Briefly describe the scene and environment at the time of the incident.
Describe Peril of the Rescued *How was the person who was rescued endangered and in need of rescue?
Describe Action of Nominee *Deacribe the actions taken by the nominee to rescue or attempt a rescue of those in peril.
Evidence LinksPlease provide Internet links to any printed media reports or other reports of the incident available on the World Wide Web.
EvidencePlease upload any evidence you believe would help us review this nomination. You may scan and upload media reports, official reports, or other material.
Evidence (2)Please upload any evidence you believe would help us review this nomination. You may scan and upload media reports, official reports, or other material.
Your First Name *		Your Last Name *
Email Address *		Your Telephone *
Your USLA Region
Your USLA Chapter

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