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Family Nomination Form
Do you know a family who has a child with a severe or life threatening illness or disease?  Fill out this questionnaire so that we can discuss their needs at our next meeting to see if they are someone that we can help. 
Email *
Your first and last name *
Your relationship to the family that you are nominating *
Parent's first and last names (mom & dad or both guardians) *
Child's name *
Where the family that you are nominating lives. (city & state) *
Does the child that you are nominating have any siblings?  If so, names and ages.  *
Please explain in detail what the child's illness or disease is called and what they are going through. *
Any other extenuating circumstances that we should know about?  (loss of job because of illness etc.) *
How can we help? *
Who should we contact to discuss further? *
What is their contact information? (phone is best) *
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