2026 Nominations

Child Nomination Form

Each year, the Rock Chalk Roundball Classic selects children and families to support as they navigate the fight against pediatric cancer. Through this nomination form, community members, friends, caregivers, and supporters may recommend a child and their family for consideration.

Please complete the form below as thoroughly as possible. The information you provide helps our Selection Committee better understand each family’s circumstances and needs. All information submitted will be treated with care, privacy, and respect, and will only be shared with the Rock Chalk Roundball Classic Board and Selection Committee.

Thank you for taking the time to help us identify families who may benefit from this experience. We are honored to learn about the incredible warriors and families in our community.

Nominator Information
Full Name*
First Last
Phone Number*
Email Address*
Relationship to Nominee*
(e.g., parent, relative, friend, healthcare provider, teacher, etc.)
Nominee Information
Child's Full Name*
First Last
Hometown*
City State
Age*
Please provide a brief overview of the nominee’s household and family dynamic*
(Parents/guardians, siblings, and others living in the home)
Parent/Guardian Contact Information
If available, please provide the best contact information for the nominee’s parent or guardian.
Parent/Guardian Full Name
First Last
Phone Number
Email Address
Medical & Treatment Information
Please provide a brief summary of the child’s diagnosis, treatment plan, and expected duration of treatment*
Financial Impact
If known, on a scale of 1–10, how would you describe the family’s current financial need?*
(1 = minimal impact | 10 = severe financial hardship)
Please describe how financial assistance would be most helpful to this family*
(e.g., medical bills, travel expenses, lodging, utilities, groceries, lost income, etc.)
Additional Support & Considerations
Have any other fundraisers or charitable efforts been held on the child’s behalf? If yes, please describe.*
If applicable, please share links to any websites or social media pages that provide more information about the nominee’s journey*
Are there any non-medical concerns that may affect the nominee’s ability to attend the weekend events?*
(e.g., mobility needs, travel limitations, scheduling conflicts)
Additional Information
Please list any additional context you would like the Selection Committee to know about this child or family?*
Photo Upload (Optional)
If available, please upload one or two photos.
Drop files here or

Accepted file types: jpg, jpeg, gif, png, Max. file size: 64 MB, Max. files: 5.
Photos may be used when announcing beneficiaries on our website, social media platforms, or other event-related materials.
Acknowledgment & Consent
By submitting this form, you give the Roundball Classic permission to use any information and photographs provided to promote fundraising initiatives and further awareness of this year's events and beneficiaries.

Submission of this form does not guarantee selection. Due to the number of nominations received and available resources, not all nominees may be selected.

2026 Nominations

Nominator Information

Nominee Information

Parent/Guardian Contact Information

Medical & Treatment Information

Financial Impact

Additional Support & Considerations

Additional Information

Photo Upload (Optional)

Acknowledgment & Consent