Members Making a Difference Nomination Form

The highest honor for a volunteer to receive in the Academy’s Leadership Circle for Volunteerism is the "Members Making a Difference Award." This Award is based on cumulative volunteer service.

One award is given each month and the winner is profiled in Dermatology World. Award winners are chosen based on the significance of the work they have done and category of service. All nominees will remain on the selection list for up to three years.

Your Information

First Name:   *
Last Name:   *
Phone:   *
Fax:
Email:     *

Nominee Information

First Name:   *
Last Name:   *
Phone:
Fax:
Email:   *

Category of Volunteer Activity






Description of Volunteer Activities

Please illustrate which activities or services performed by the nominee caused you to nominate this individual   *

What is your relationship to the nominee