Crossing the Finish Line

Excursion Inquiry

To request a nomination form be sent to you, please provide the requested information. (Note: that if you complete this information, you have NOT nominated an individual. Rather, you have requested the Nomination Form and Sailor Acknowledgement be sent to you. A nomination is not formal until completed by a member of the sailor’s oncology team and acknowledged by the sailor himself/herself. Thank you for your cooperation.)

To request a nomination form be sent to you, please complete the following information and press submit at the bottom of the form:

* First Name		Middle Initial
* Last Name
* Address
* City
* State	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico, US Territory Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
* Zip
* Phone Number
* Email
Professional Affiliation
How did you hear about Crossing the Finish Line?
Name of Potential Sailor and any other information that may be helpful in becoming familiar with potential excursion recipient: