The Amanda Dempsey Award
Presented by Amgen Breakaway
from Cancer
Basic Criteria for Nominee
• Individual is a cancer survivor
• Individual demonstrates passion for helping others diagnosed with cancer
• Individual is actively involved in community outreach
• Individual inspires others by their demonstrated passion
• Individual lives and/or ‘helps others’ in the state of Maine
Please cite specific examples of accomplishments, projects, community outreach and/or
examples of the nominee going the extra mile to help others.
Deadline for nominations: Noon, August 25, 2014
Nominee Information
Name _______________________________________________
Phone _______________________________________________
E-mail _______________________________________________
Your Information
Name _______________________________________________
Phone _______________________________________________
E-mail _______________________________________________
Does this person know that you are nominating them for this award?
Yes
No
On the back of this sheet, or a separate piece of paper, in 500 words or less, please explain why
your nominee should receive this award. Typed, handwritten or online submissions will be
accepted.
Please submit your completed form to:
Renee Courtemanche
Central Maine Medical Center
300 Main Street
Lewiston ME 04240
E-mail: courtere@cmhc.org
If you prefer to submit online, a form is available at www.dempseychallenge.org