Champions of Hope Nominations

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Nominee's Name *

Nominee's Address *

Nominee's Telephone Number *

Nominee's E-mail Address

Your Name *

Your Address *

Your Telephone Number *

Your E-mail Address *

Why are you nominating this person? *

How long have you known her, or him? *

How has this person made a difference, and what is their unique contribution to our cause? How have they made an impact? *

Please tell us your candidate's story, explaining how he/she has contributed as a Champion of Hope in the fight against cancer. *

What is their experience in the community in work against Cancer? *

What else should we know about your candidate as a Champion of Hope? *

Please note that we will be sharing your nomination with your nominee, unless otherwise requested by you: *