CLIMATE CHANGE AND HEALTH GOOD PARCTICE AWARDS

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					CLIMATE CHANGE AND HEALTH GOOD PRACTICE AWARD Entry Form
Please complete this entry form to enter the Climate Change and Health Good Practice Award. PLEASE TYPE AND SUBMIT THE ELECTRONIC FORMAT BY EMAIL TO jana@env-health.org. Ms. Janaina Topley Lira Health and Environment Alliance 28, Boulevard Charlemagne, 1211 Brussels, Belgium Email: jana@env-health.org Fax: +32 2 234 3649 Telephone: +32 2 234 3647 To help reduce the carbon footprint of this competition please do not print and fax this entry form unless it is really necessary!

CLOSING DATE FOR APPLICATIONS: 23 May 2008

ENTRY FORM

Organisation: Contact Person Address: Position Tel: Fax: Email: Category Applied For □ Mitigation □ Adaptation Project Title

Type of organisation

 Local or regional public authority  Academic institution

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Climate Change and Health Good Practice Awards

 Health care sector establishment  Other (please explain)
Sector

    

Health Environment Transport Energy Education

Project Goals
(No more than 200 words)

Project Description
(No more than 200 words)

Benefits to health (Please explain how your
project is yielding quantifiable health benefits) (No more than 200 words)

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Climate Change and Health Good Practice Awards

(Expected) Results
(No more than 200 words)

Lesson’s Learned
(No more than 200 words)

Target Audience
(Children, adolescents, vulnerable patient groups, elderly people, employees)

Timeframe

Partner organisations

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Climate Change and Health Good Practice Awards

Financing Cost
(How much did the activities cost? How was the project paid for?)

Follow-up Plans
(No more than 200 words)

Please attach supporting material of the good practice

As the judges will not be able to conduct on-site visits, applicants are encouraged to submit supporting materials including but not limited to: photographs, technical descriptions, news clippings, and press releases. Please note that all submissions are final and neither the application nor supporting materials will be returned. Supporting material can be submitted in original languages.

CONTEST RULES

ELIGIBILITY I agree to the following: A project description, together with project contact details will be posted on a Climate Change and Health Good Practice Awards website: http://www.envhealth.org/climatechangeawards

If my project is selected to be presented at the “Climate Change and the Challenges for Public Health: Engaging the Regions” Conference 24 June, 2008, I shall: Be available to attend the meeting in Brussels Signature ……………………..

Place and date ………………………..

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Climate Change and Health Good Practice Awards


				
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