Washington State Athletic Trainers’ Association
Hall of Fame
The nominating athletic trainer shall be responsible for the completion of all sections of the application and must mail completed nomination forms, postmarked by February 1 to:
Katy Pietz, ATEP
WSATA Awards Committee Chair
WashingtonStateUniversity
PO Box 642136
Pullman, WA 99164-2136
THIS AWARD WILL BE PRESENTED AT THE WSATASTATE MEETING AT THE DISTRICT 10 ANNUAL CLINICAL SYMPOSIUM IN MARCH
Name of nominating athletic trainer ______
Employer ______
BOC Certification # ______NATA Member # ______
Correspondence Information
Telephone # (daytime) ______(evening) ______
Email address ______
WashingtonState Athletic Trainers’ Association
Hall of Fame
Nomination Form
MUST BE TYPED
Name of nominee ______
Home Address:
Street Address ______
City ______State ______Zip ______
Work Organization:______
Street Address ______
City ______State ______Zip ______
Phone:
Office ( ) ______Home ( ) ______
Fax ( ) ______E-mail ______
Position: ______
Credentials (other than ATC): ______
BOC Certification # ______
Professional Education:
Degree EarnedSchoolYears of Attendance
______
Career History:
PositionOrganizationDates
______
SECTION I: STATE & LOCAL CONTRIBUTIONS
1. Has the candidate served on a Washington State Athletic Trainer Association Committee?
CommitteeYearsChair (Y or N)?
______
2. Has the candidate held an office in the State Association?
OfficeYears of Service
______
3. Has the candidate been recognized at their place of employment for exceptional job performance?
AwardLocationDate
______
4. Has the candidate spoken at other organizations to promote the profession of athletic training?
Name of OrganizationLocationDate
5. Has the candidate been active with any local service organizations (ie church involvement, United Way, Red Cross, other)?
Name of OrganizationLocationDate
______
SECTION II: DISTRICT & NATIONAL LEVEL CONTRIBUTIONS
1. Has the candidate regularly attended District and National Meetings? Please list years attended. District ______
National ______
2. Has the candidate spoken at any District or National Meetings and/or participated in student clinics or workshops?
DateTopic
______
______
3. Has the candidate served on any District or National Committees?
CommitteeYearsChair (Y or N)?
______
4. Has the candidate held an office in the District Association or at the National Level?
OfficeYears of Service
______
5. Has the candidate been a model/examiner/administrator for the BOC exam?
PositionLocationDate
______
6. Has the candidate won any awards at the District or National Level?
AwardDate
______
7. Has the candidate been published in any journals or books?
Article or Book TitlePublication Date
______
Please provide a statement in support of your nominee. Consider areas such as: dedication & service to the profession, improving the profession and work environment, leadership, philosophies, research endeavors, etc. Please limit your response to 750 words.