2023 Selfless Samaritan Award Nomination Form

Nomination deadline is April 15, 2023. Award recipient will be recognized during the Silent Samaitan Thank You Celebration on May 18, 2023.

Nominate a deserving individual today!

Fill out the online nomination form below or download a printable version to mail to us.

Your Name(Required)

First Name Last Name

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Relationship to Nominee(Required)

Nominee Name(Required)

First Name Last Name

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

Tell us why your nominee deserves the Selfless Samaritan Award(Required)

Comments

This field is for validation purposes and should be left unchanged.

Menasha Center & Admin Offices
1205 Province Terrace
Menasha, WI 54952

(920) 886-9319
(920) 486-5340 (fax)

First Presbyterian Church
110 Church Ave
Oshkosh, WI 54901

(920) 235-1678
(920) 486-5340 (fax)

United Methodist Church
709 W. Pine St
New London, WI 54961

(920) 982-7863
(920) 486-5340 (fax)

Immanuel United Church of Christ
510 Sullivan Ave
Kaukauna, WI 54130

(920) 886-9319
(920) 486-5340 (fax)