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Please complete all boxes to tell us how you intend to implement The DAISY Award program.

VERY IMPORTANT:  Please inform your IT Department to allow all emails from DAISYFoundation.org to reach you as most of our communication is via email.

About Your Organization








Multiple Facility Information



Location 1 Multiple Facility Information
Please enter location information for all of your participating locations below. This will ensure that your patients or their families will be directed to you if they wish to nominate one of your nurses using our website. If you have this information on a spreadsheet and would prefer to attach that, please change your selection above to "spreadsheet". Thank you!



Location 2 Multiple Facility Information



Location 3 Multiple Facility Information



Location 4 Multiple Facility Information



Location 5 Multiple Facility Information



Location 6 Multiple Facility Information



Location 7 Multiple Facility Information



Location 8 Multiple Facility Information



Location 9 Multiple Facility Information



Location 10 Multiple Facility Information



Location 11 Multiple Facility Information



Location 12 Multiple Facility Information



Location 13 Multiple Facility Information



Location 14 Multiple Facility Information



15+ Multiple Facility Information

Spreadsheet Multiple Facility Information

Your DAISY Plan


About Your DAISY Coordinator
Who will be our main contact?







About Your Chief Nursing Officer
Please complete the following information as it should appear on your DAISY Award Certificate Template and to help us stay in touch with your CNO:






About Your Chief Executive Officer
So we may thank your Chief Executive Officer or Chief Operating Officer for her/his support for honoring your nurses, please tell us:





Additional Contacts:
Additional Contacts are not required, but are requested if you have someone in place at this time.
DAISY Co-Coordinator: Do you have a Co-Coordinator in mind that you would like included in our communications?






Administrative Support:
Please tell us if someone is providing administrative or clerical support to your DAISY Award, Program, such as an assistant or clerical person.





Marketing Support:

We recommend having someone from your marketing department work with your DAISY committee to raise awareness of your program among patients, families and staff.  Please tell us if you would like us to contact one of your marketing representatives to assist in this process.




Shipping Information:
Once a year, we will ship your DAISY Award gifts for all facilities you have noted above. Please designate to whom we should ship by completing the information below in as much detail as possible.
















Funding Your DAISY Award Program
When you commit to The DAISY Award by completing this form, we will email an invoice to the person you designate below. This will pay for your first year's DAISY gifts and everything you need to get your program underway. We ask that you pay it within 60 days of commitment so that we have everything you need for your program when you need it. Thank you!







Finally...




By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps.  To learn more, please read our Privacy Policy.

Contact Information