The Future of Health Information Award recipient form

Congratulations on being selected as a recipient of CHIMA’s Future of Health Information award.

Please complete the form below to receive your prize package including $250, a one-year subscription to CHIMA’s Annual Team Learning Subscription, and recognition across CHIMA’s communication channels.

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Address(Required)

Please ensure your address is accurate as your certificate will be mailed to this address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Academic Institution Address

If opting to have the cheque mailed to your academic institution, please ensure your program coordinator/manager, has been notified and confirmed the correct mailing address.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

What educational institution do you currently attend?(Required)

CHIMA Membership Number(Required)

Please provide your LinkedIn handle.

Note: Your photo on your LinkedIn profile will be used, if available, for CHIMA communications.

Congratulations on being selected as a recipient of CHIMA’s Future of Health Information award.

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