Your nomination
Who are you nominating?*
Please enter the name of the person you are nominating
Their email:*
Please provide the email address of the person you are nominating
Their telephone number:*
Please provide the telephone number of the person you are nominating
Their address:*
Please provide the address of the person you are nominating.
Their postcode:*
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If your nomination is for the 'Rising Star' or 'Young Star' category, please state the age they will be on 26 March 2014*
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Please confirm that you have the consent of the nominee to provide us with this information, which will only be used for this event*
I have consent of the nominee Please confirm you have the consent of the nominee.
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Your award entry
What is their relationship to you?*
Please tell us
Tell us about the person, group or organisation you are nominating (no more than 200 words):*
Please tell us more
Why do you think this nominee should win this award? Please give examples. (No more than 200 words):*
Please tell us why they should win
If you'd like to add anything to support your nomination (testimonials, examples, photos or videos), you can attach the files here (no more than 5MB).*
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Your details
First name:*
Please provide your firstname
Surname:*
Please provide your surname
Email address:*
Please give us your email address
Telephone:*
Please give us your telephone number
Address:*
Please confirm your address
Postcode:*
Please confirm your postcode
Your age if under 18 years:*
Please confirm
If you'd like to be kept updated on the Champions Awards and other news from Young Epilepsy, please let us know.*
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How did you hear about this event?*
Web search Facebook Twitter Email From a friend or relative I work for Young Epilepsy Newspaper/Magazine From my school From my health organisation From local authorities Parent support group Other
If you selected 'other', please specify*
Please check all the fields above to ensure you have given us as much information as possible and then please submit your entry
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