Cervivor Cares Gift Card Fund Nomination Form

Cervivor Cares Gift Card Nomination Form

We are dedicated to supporting cervical cancer patients and survivors in our community. Our Cervivor Cares Gift Card Fund aims to provide assistance with essential expenses such as gas, groceries, medications, and day-to-day costs, helping to alleviate some of the financial burdens associated with cancer treatment and recovery. If you know a cervical cancer patient or survivor who could benefit from this support, please take a moment to complete this nomination form.

Please select one:

I am the nominee.

I am nominating someone else.

Nominator's Name:

First

Last

Nominator's Address:

City

State/Province

Zip/Postal

Country

Nominator's Phone:

Nominator's Email Address:

What is your relationship to nominee?

Would you like your nomination to remain anonymous?

Yes, I would like my nomination to remain anonymous.

No, I do not want the nomination to be anonymous.

Nominee's Name:

First

Last

Nominee's Address:

City

State/Province

Zip/Postal

Country

Nominee's Phone Number:

Nominee's Email Address:

Where are they/you currently in their/your cervical cancer journey?

Newly Diagnosed

Treatment in Progress

Received Recurrent or Metastatic Diagnosis

New in Survivorship [Less than 1 year]

Survivorship [1 year +]

OtherOther

In our efforts in providing services with diversity, equity, and inclusion as a top priority, we ask if you would kindly share the recipient/your ethnicity.

Nominee's Current Challenges (Check All That Apply):

Gas/Transportation Expenses to Medical Appointments

Groceries/Food Expenses

Medications/Medical Expenses Not Covered By Insurance

Day-to-Day Living Expenses Due to Reduced Income During Treatment

OtherOther

Please utilize this space to share why you are nominating yourself or this individual:

Is there any additional information you'd like to share about the nominee or their situation?

Important Notes

You will receive a confirmation of this gift card recipient nomination. While we strive to accommodate all requests, we must consider overall funding and our ability to provide the gift card in a timely manner. Please note that international nominees will not be considered at this time.

By submitting this form,

I certify that the information provided is accurate and true.

The nominee's information will be kept confidential and used solely for the purpose of evaluating their eligibility for the Cervivor Cares Gift Card Nomination Form.

If you are human, leave this field blank.