Required fields are marked with asterisks (*)

Medicine Hat Sports Wall of Fame Application

If you have any questions or concerns, please e-mail parks@medicinehat.ca or phone 403-529-8333.

Submission deadline is September 30.

Contact Information

Name of nominator

Relationship to nominee

Address

City

Postal code

Email address

Phone number

Fax

Signature

Clear

Date

Nominee Information

Name of nominee

Name and title of team/organization contact

Address

City

Postal code

Email address

Phone number

Fax

*By signing below, the nominee agrees (if possible) to participate in the public reception and plaque unveiling hosted by the City of Medicine Hat. The nominee also agrees to have the information included in this application made public (if the nominee is selected).

Signature of nominee

Clear

Date

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