Commit to The DAISY Award

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

Name of institution as you would like it listed on our roster: *

Name of your healthcare system, if applicable:

Multiple Facilities: If multiple facilities will participate in your DAISY Award program, please list each one along with the number of nurses in that facility in a box below. Example: Baptist South, Memphis, TN, 552 Nurses. For Clinics, you may leave the address blank, but please tell us the total number of clinic nurses who will participate in the program. Example: Clinics, 37 Nurses.

Are you a Magnet-designated Organization? *

Are you a Pathways to Excellence-designated Organization? *

Approximate number of nurses: *

Approximate number of beds: *

Your organization's website: (www.yourwebsite.org) *

Your DAISY Plan

Please select the total number of DAISY Awards you expect to present each year in all your locations: *

# of "Other" DAISY Awards (if selected "Other" above) *

When do you anticipate presenting your first Award? (We realize you do not have a specific date now, so please insert an approximate date for planning purposes only.) *

Is there a Cinnabon bakery in your area? *

If you are unsure about a nearby location, please click here. At the very top of Cinnabon's home page, you'll see Locate a Store. Click on that to find your closest bakery.

Please note: Cinnabon® offers coupons for two complimentary boxes of their cinnamon rolls for all of your DAISY Award presentations. If they are not in your area, we appreciate your providing cinnamon rolls for your DAISY Award presentations from another bakery or your hospital cafeteria. We will send you jars of Cinnabon's cinnamon. Thanks!

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!

What is the projected source of funding? (E.g. name of your hospital or organization, Corporate or Family Sponsor if you have one, Foundation funding the program, etc.) *

Name of invoice recipient: *

Invoice recipient's email: *

Invoice recipient's phone: (555) 555-5555 *

How would you like to pay for your DAISY Award program?

You have several options to facilitate payment of your invoice from The DAISY Foundation. We accept Checks, Electronic Funds Transfers (EFTs), or major Credit Cards like Visa, MasterCard and American Express. Please note that a $25 processing fee will be added for Credit Cards. More information will be provided on your invoice.

Payment Method *

Your payment might be expedited, if your accounting department uses this system, by establishing a Purchase Order to cover your DAISY Award Program costs. If and when you have a purchase order, please email it to Yvonne at yvonneoleary@daisyfoundation.org, and she will include the Purchase Order Number on your DAISY Invoice.

Please let us know if your accounting staff has any other information requirements in order to process payments.

About Your DAISY Coordinator

Who will be our principal contact?

DAISY Coordinator first name: *

DAISY Coordinator last name: *

DAISY Coordinator credentials:

DAISY Coordinator title: *

DAISY Coordinator email: *

DAISY Coordinator phone: (555) 555-5555 *

Name of the committee or team that will run The DAISY Award at your organization: *

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.

Ship to organization name: * Name of your hospital or facility

Ship to name: *

Ship to title: *

Ship to email address: *

Ship to phone: (555) 555-5555

Ship to unit, floor, mailstop (whatever it will take to ensure our packages get to you):

Ship to Street address: (no PO Box please!) *

Ship to City: *

Ship to State:

Ship to Zip code: (all 9 digits please) *

If not in the USA, please type in the entire address as it should appear on a shipping label here:

Ship to country: *

About Your Chief Nursing Officer

Please indicate the following information as it should appear on your DAISY Award Certificate Template and to help us stay in touch with your CNO:

CNO first name: *

CNO last name: *

CNO credentials: *

CNO exact job title: *

CNO email: *

CNO phone: (555) 555-5555 *

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:

CEO first name: *

CEO last name: *

CEO credentials, if applicable:

CEO exact job title: *

CEO email: *

Finally...

How did you hear about The DAISY Award program? *

Additional comments:

Name of person who completed this form: *

Email of person who completed this form: *

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