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Wyoming Governor's Council on Physical Fitness and Sports Excellence in Health Award Application

Applicant's Name (Individual) Place of Employment
OR
Name of Organization Type of Business
Number of Employees (if applicable)  
Name of Person or Organization Award is Being Applied for (self-nomination is accepted)
Address 
Phone Number Email Address

Section 1: Success Stories/Reason

Please provide a reason why this individual or organization should qualify for this award:
Please document below a success story of the efforts of this individual or organization:

Section 2: Effectiveness in increasing physical activity or wellness

Please list why you believe the efforts this individual or organization have led to increased physical activity or wellness in others:
Please list all of the positive outcomes that have resulted from the efforts of this individual or organization:

Section 3: Efforts to promote healthy lifestyles

Please list any other efforts this individual or organization has led in regards to physical activity or wellness:
Please list all of the positive outcomes that have resulted from the efforts of this individual or organization:

Section 4: Credibility

Please give two references with contact information that we can reach out to for verification of this individual or organization:
Reference 1: 
Address: 
Phone Number:    Email Address: 
Reference 2: 
Address: 
Phone Number:    Email Address: 

Section 5: Ability to work with other groups and organizations for the cause

Please list individuals, groups or organizations that this individual or organization has collaborated with for efforts related to physical activity and wellness:
 
 
 
 
 
 

Please provide contact information for two of those individuals or organizations:
Contact 1: 
Address: 
Phone Number:    Email Address: 
Contact 2: 
Address: 
Phone Number:    Email Address: 
 
 
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