2. 
4. The City of La Vista would like to recognize those in our community who have been working on the front lines of the COVID-19 pandemic.
   Please fill out the form below to nominate a friend or family member who lives in La Vista and works in the healthcare industry.
6. Information for person making the nomination
8. Name*
10. E-mail address*
11. Phone number*
13. Information for the nominee
15. Name*
17. E-mail address
18. Phone number
20. Profession*
21. Employer*
22. Years in the healthcare industry*
24. What is the best time of day and method to reach them?*
26. Why are you nominating this person? *
Leave This Blank:


27. 1. Receive an email copy of this form.
28. Email address

    This field is not part of the form submission.

29. Submit

* indicates a required field