Star of Life Nomination Form

  • Region where incident occurred.
  • Date Format: MM slash DD slash YYYY
  • Patient's NamePatient's E-mailPatient's Phone NumberPatient's Diagnosis 
    To add multiple patients, please press the + icon at the far right of the row.
  • Drop files here or
  • Drop files here or
    This form can be found on the CECA Website under the Star of Life Award tab.
  • Ensure all agencies are listed and their names are spelled correctly. This list is what will be used to engrave the Stone Awards which will be handed out to each EMS Regional Winner. To add multiple agencies, please press the + icon at the far right of the row.
  • AgencyFirst nameLast nameE-mailCell phone 
    Please list all pre-hospital providers involved with this incident. To add multiple providers, please press the + icon at the far right of the row.
  • Drop files here or
    Photos of the EMS personnel and patients being nominated. Photos to be used in event program and presentation.
  • Name of Media OutletPoint of Contact NameAddressE-mailPhone Number 
    Please list all media and their contact information that you would like the CECA office to invite to the ceremony and supply a press release to at the completion of the event. To add multiple media outlets, please press the + icon at the far right of the row.
  • We continuously strive to improve the Star of Life Award ceremony each year. Please let us know if you have any suggestions or ideas on how we can improve this event.
  • If you need to save your work throughout the submission process, the page will refresh once the save and continue button is selected. It will provide you with a link that is valid for 30 days.