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  • Submitter's Information

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  • Healthcare Hero Information

  • Name * Required
  • Accepted file types: jpg, png, pdf.
  • Is it okay to contact you for additional information or an expanded interview with a member of the WHCA staff? * Required
  • Health Care Hero Waiver/Release Must be Given by Individual in Image
  • Released Entirely to WHCA * Required
  • Sole Property of WHCA * Required
  • Statements Reflect my True and Accurate Beliefs * Required
  • I am Eighteen Years of Age or Older * Required