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Call for Nominations:

MCW Consortium on Public & Community Health

Wisconsin-based organizations are invited to submit nominations of individuals to serve as a member of the Medical College of Wisconsin (MCW) Consortium on Public & Community Health, the board which oversees the community-focused funds of the Advancing a Healthier Wisconsin Endowment (AHW). Nominations must be submitted using this online form. No paper or email applications can be accepted. The online form only supports Plain Text. No text effects such as bold, italics, underlining, bulleting, numbering, etc. will be captured in the final submission. The deadline for nomination submissions is February 28, 2025 by 12:00 pm CT. Late nominations will not be accepted.

The nominating organization will be required to designate on the nomination form one point-of-contact for questions or additional information from the committee. Following the successful submission of a nomination, the nominating organization’s designated contact will receive an email confirming submission of the nomination form. The nominee will then receive an email notifying them of their nomination and asking the nominee to confirm interest. The nominee will also have the opportunity to provide both demographic and additional information to the nominating subcommittee. The nominee is asked to submit this information within two business days of receipt of the email in order to move to the next stage of the selection process.

Nominator Information

In accordance with a 2002 Order of the Commissioner of Insurance, potential members of the MCW Consortium on Public & Community Health board must be nominated by a Wisconsin-based organization that has been in operation for more than five years, and is independent of influence of Wisconsin’s two schools of medicine and Blue Cross & Blue Shield United of Wisconsin and its affiliates.

Please provide the following information as the nominating organization:

Nominating Organization:

Organization Website:


Organization Address:	Street	City	State	ZIP


Nominator's Name:	First (individual who may serve as the contact for any questions regarding the nomination)	Middle	Last (individual who may serve as the contact for any questions regarding the nomination)	Suffix/Credentials

Preferred Name

Pronouns

Work Phone:

Cell Phone:

Email Address:

I certify that this organization is:

Wisconsin-basedHas been in operation for at least five yearsIs independent of influence from the Medical College of Wisconsin,

the University of Wisconsin School of Medicine and Public Health,

and Blue Cross Blue Shield United of Wisconsin and its affiliates

Nominee Information

Please provide the selection committee with the following information regarding your nominee:


Nominee Name:	First	Middle	Last	Suffix/Credentials

Nominee Employer:

Nominee Current Employer:

Organization Website:


Employer Address:	Street	City	State	ZIP

Nominee Job Title:

Nominee Work Phone:

Nominee Cell Phone:

Nominee Email Address:

Nomination Category

At this time, AHW is seeking one Consortium member to fill a vacancy in the category of community health advocate.

Please select one (or more) of the categories your nominee represents:

Community health advocate - Advocate concerning health issues of particular concern to a minority communityCommunity health advocate - Advocate concerning health issues of particular concern to senior citizensCommunity health advocate - Advocate concerning children’s health issues Community health advocate - A representative of a non-profit or local governmental community health organization other than a rural community health organization

Narrative Questions

Please tell us about the nominee, their experience, expertise and level of influence in relation to Wisconsin’s health needs:

Why does your organization believe this individual will be an asset to the mission of the Advancing a Healthier Wisconsin Endowment as well as its public stewardship responsibility of the community funds?

Provide examples of the nominee’s work or engagement with diverse communities (using a broad definition of diversity such as urban/rural communities, disability groups, veterans, gender, racial and ethnic populations, etc.) and commitment to health equity.

Describe the nominee’s board governance experience:

Describe the nominee’s experience with fund development and philanthropy:

Resume/CV Submission

Please upload a PDF of the nominee’s current resume/CV here.

Following submission, the nominator contact will receive an email confirmation of submission. In addition, the individual who is nominated will receive an email with notification of their nomination that includes an additional demographic questionnaire as well as an opportunity to share further information about themselves.

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