Commit to the DAISY Award

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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 to reach you as most of our communication is via email.

About Your Organization

Your DAISY Plan


About Your DAISY Coordinator

Who will be our principal contact?

Additional Contacts
*Additional Contacts are not required but are requested if you have someone in place at this time.


DAISY Co-Coordinator:

Do you have a Co-Coordinator in mind that you would like included in our communications?

Administrative Support:
Please tell us if someone is providing administrative or clerical support to your DAISY Award, Program, such as an assistant or clerical person.


Marketing Support:

We recommend having someone from your marketing department work with your DAISY committee to raise awareness of your program among patients, families and staff.  Please tell us if you would like us to contact one of your marketing representatives to assist in this process.

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.

Name of your hospital or facility

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!

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: Visa or MasterCard. More information will be provided on your invoice.

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 Jennifer at, 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 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:

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: