Central Oregon Disaster Restoration
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Lifting Up a Local Nomination Form
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Please enable JavaScript in your browser to complete this form.
All nominations must be received by October 18th.
Our final selection will be announced November 1st.
Nominator’s Information
Full Name:
*
First
Last
Phone Number:
*
Email Address:
*
Relationship to Nominee:
*
(e.g., friend, family member, coworker, etc.)
Nominee’s information
Full Name:
*
First
Last
Phone Number:
*
We will reach out to see if they are comfortable being nominated.
City of Residence:
*
Nominee’s Situation
Brief Description of Nominee's Breast Cancer Journey:
*
Explain their current situation, stage of treatment, and any challenges they are facing. Focus on how breast cancer has impacted their life and family.
How Would Financial Assistance from CODR Help the Nominee?
*
Provide specific examples of how this donation could help alleviate burdens.
Additional Information (Optional)
Is there anything else you'd like us to know about the nominee?
Consent/Privacy Acknowledgement
I confirm that the nominee has consented to sharing this information with CODR for consideration of this project.
I understand that the informatino provided may be shared internally at CODR for selection purposes and that CODR will handle all personal information with confidentiality.
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