2019 Nominations

Every year, we select children to help in their fight against cancer. We call them our Starting Five. Using this form, anyone can nominate a child and their family. Fill out the forms below to begin. Be sure to include any information you think we might need. Anything you can tell us will help us make our selections.

We can’t wait to see what inspiring nominees you send to us this year!

Your Information
Name*
First Last
Email*
Nominee Information
Name*
First Last
Age*
Hometown*
City State
Brief Recap of the treatment procedures and duration:*
On a scale of 1 to 10, how severe is the family's financial need?*
What specifically would the proceeds be used for (in terms of paying off medical bills, other debt incurred by this illness):*
Have any other fundraisers or charitable efforts been done on the child’s behalf? If so, please describe.*
What does the family’s current support system look like? Would there be a contingent of friends / co-workers willing the pitch in and volunteer?*
Is there anything else we should know about this nominee?*
If you have any available, attach a photo or two that we might be able to use when announcing our 2019 beneficiaries on our website, Facebook page or other marketing material.
Drop files here or
Accepted file types: jpg, jpeg, gif, png, pdf.
Files must be 8 MBs or less.

2019 Nominations

Your Information

Nominee Information