Nominate someone for the Vitiligo Innovators Program™

Nominations are due October 31, 2024.

Thank you for your interest in the Vitiligo Innovators Program™ (VIP). You can nominate someone by filling out the below form or by downloading this PDF and submitting it via email to VIP@realchemistry.com.

Before you begin to fill out your nomination form, please ensure you review the following carefully:

Before submitting your nomination, please ensure that all information is accurate and correct, as you will not be able to edit or save the form after submitting. For questions, please review the FAQs or email us at VIP@realchemistry.com.

01: Nominee Information

Name of Nominee Required field

Nominee Job Title Required field

Nominee Affiliations Required field

Nominee Phone Number Required field Invalid Phone Number

Nominee Email Address Invalid Email address

Nominee Address Line Required field

Nominee Address Line 2 (optional)

City Required field

State Required field

ZIP Required field Invalid Zip Code

Name of Nominator Required field

Nominator Phone Number Required field Invalid Phone Number

Nominator Email Address Invalid Email address

Nomination Category

02: Nomination Category

Please indicate which category you are nominating for:

Healthcare Innovator: Healthcare professional (i.e., nurse, PA, physician) who provides extraordinary care and/or education for people with vitiligo. Types of work recognized could include dedication, or care, that goes "above and beyond" for patients.Rising Innovator: Promising resident, medical student or researcher who focuses on advancing research in vitiligo. This person has demonstrated significant contributions to advancing the understanding of vitiligo and/or disease management. Types of work recognized could include authoring, or presenting relevant vitiligo research.Community Innovator: An advocate or non-medical individual who has made a significant positive impact in supporting, or caring for, people with vitiligo. Types of work recognized could include significant advocating efforts on behalf of the community, impactfully driving awareness of vitiligo, or even being a caregiver to a person living with vitiligo in a meaningful way. Required field

Nomination Form

03: Nomination Form

IMPORTANT! An independent judging panel will review your written explanation of why your nominee should be recognized.

What extraordinary efforts highlight your nominee’s commitment to impacting the lives of people with vitiligo? (750 words maximum) Please describe your nominee’s actions and accomplishments in as much detail as possible. Required field

Acknowledgments

04: Acknowledgments

I have read and agree to all terms as outlined above. Required field

I attest that the responses provided in this form are true and accurate to the best of my knowledge and that the nominee will be made aware of the nomination and that the nomination will need to be approved by and compliant with any institutional rules and guidelines. Required field

Submit Nomination

Submit a nomination for the Vitiligo Innovators Program™ (VIP)

01: Nominee Information

02: Nomination Category

03: Nomination Form

04: Acknowledgments