Nomination Form

Recipient Information
Recipient Name*
First Last
Gender
- Male
- Female
Birthdate*
MM
DD
YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email
Senior Living Community Name (if applicable)
Check all that apply*
- Elderly
- Disabilities
- Chronic Illness
Upload Pictures of Recipient (optional)

Nominator Information
Is nominator same as recipient?*
- Yes
- No
Name*
First Last
Relationship to Recipient
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email

Getting To Know Recipient
If you are nominating someone, please remember that the questions below refer to the recipient. Be as detailed as possible with your answers.
What are some of the challenges, difficulties, or trials that the recipient is currently facing in their life?*
What are some of the recipient’s interests, hobbies, occupations, and passions? Do they still participate in any of these today?*
What is something the recipient wishes they could do but currently are unable to?*
What positive impact has the recipient had on those in the community?*

Project Description
How can Udo Gives help? Be specific on what you are asking of us.*
Why would this be important to the recipient and how would it provide hope to them?*
What accommodations would we need to plan for? (ie, wheechairs, oxygen, caregiver, dementia, etc.)*
Disclaimer
By submitting this nomination form, I acknowledge that acceptance of this nomination by Udo Gives does not constitute a commitment by Udo Gives to fulfill this request. If the nomination moves to the next stage, an Udo Gives representative will contact me for more information. I understand that this contact also does not constitute a commitment to grant my request. Furthermore, I certify that I meet all qualifications for eligibility, and declare that all of the information given by me in this application is true to the best of my knowledge, and I agree to inform Udo Gives in a timely manner should any information be provided in this application change.

Recipient Information