Nominations

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All information provided is strictly confidential and will be treated with the utmost discretion and respect for privacy.

Needs

Food
Clothing
Assistance

Why are you nominating this person?

Nominee Details

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Checkboxes

I would also like to help.

Your Details

Name

First

Last

Email

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code