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Business Recognition Program Nomination Form

  1. The Walworth County Department of Health and Human Services is working to help our county businesses recover from and mitigate the effects of the COVID-19 pandemic. To support these important health and safety initiatives, all businesses in Walworth County are encouraged to participate in the “Stay Well in Walworth” Business Recognition Program. This program recognizes local businesses that have effectively applied Walworth County’s COVID-19 Phased Guidance to help keep their customers, employees and communities healthy and safe. For additional program details, Walworth County COVID-19 updates, and the current Public Health Guidance, click below:
  2. Please complete the information below to submit your business nomination for the Walworth County Department of Health and Human Services "Stay Well In Walworth" Business Recognition Program. Thank you for your active participation.
  3. Additional Information:
    Please include additional business information supporting their safe practices.
  4. Consent and Submitter's Information
    I certify I am authorized to allow the Walworth County Department of Health and Human Services to use any information submitted on this form, including videos, pictures, and logos submitted, to recognize the above-named business.
  5. Leave This Blank:

  6. This field is not part of the form submission.