World Thrombosis Day 2025 Patient Ambassador of the Year - Nomination form

World Thrombosis Day 2025 Patient Ambassador of the Year: Nomination Form

Thank you for your interest in the WTD 2025 Patient Ambassador of the Year Award. Eligible candidates for the WTD 2025 Patient Ambassador of the Year Award include a thrombosis advocate, thrombosis patient, thrombosis survivor, community volunteer, and/or a thrombosis-related organization representative. You can nominate yourself or someone you know. Please note that healthcare professionals and current WTD steering committee members are not eligible to apply. If you have questions about the nomination form, please contact Sam Nelson at wtd@isth.org. Thank you!

Your name(Required)

Your title/role(Required)

Your city and country(Required)

Email(Required)

Name of the person you are nominating(Required)

First Last Suffix

If you are nominating yourself, please include your name again here.

Nominee's country of residence(Required)

Nominee's email address(Required)

Nominee's title and/or role(Required)

About the nominee

Is the nominee a WTD partner or has he/she been involved in WTD in the past?(Required)

Are you nominating yourself or are you nominating someone you know?(Required)

Why do you feel this individual should be recognized as the Ambassador of the Year?(Required)

Please include as much detail as possible.

How has the nominee positively impacted thrombosis awareness in his/her community?(Required)

Has the nominee interacted with local media or other stakeholders? If so, please share.(Required)

Provide examples of how this person has helped to lead an awareness program, campaign or advocacy initiative.(Required)

Please be specific and include examples of activities, events or awareness opportunities the nominee has organized or participated in.

What results were accomplished through this person’s awareness/advocacy efforts? Provide an example of how this person has made additional contributions to the thrombosis awareness community, either through community service/volunteerism, promoting community enhancements for the greater good of the thrombosis community or other positive achievements.(Required)

How does the nominee motivate others to engage in awareness-building efforts?(Required)

Please provide any additional information about the nominee that you would like the selection committee to consider as part of your entry application (optional).

Please upload a photo of the nominee.(Required)

Drop files here or

Max. file size: 32 MB, Max. files: 10.