Nomination & Application Form

SECTION 1 - Nominator Information

Full Name

First

Last

Age

Gender

Relationship to Nominee

Email

Phone Number

Address

Address Line 1

Address Line 2

City

State

Zip Code

SECTION 2 - Nominee Information

Full Name

First

Last

Age

Gender

Relationship to Nominator

Email

Phone

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

SECTION 3 - Medical Hardship and Impact Narrative

Please describe the nominee's medical condition, treatment plan, and how it has affected them and/or their family financially and emotionally. Please also explain the nominee's current financial hardship due to the medical condition. Include specific examples such as lost income, increased medical bills, or inability to pay for daily essentials etc.

Be as detailed as possible.

SECTION 4 - Desired Assistance

What type(s) of support would be most helpful for the nominee? (Check all that apply)

Other Essentials

- must Supporting

SECTION 5 - Optional Supporting Documents

You may upload photos or documents that illustrate your situation (completely optional). Examples include:

Medical records or diagnosis
Bills or invoices
Proof of hardship
Pictures & other helpful materials

Sharing these strengthens your nomination, though it's not required.

Upload your files in the box below:

Drag & Drop Files, Choose Files to Upload

Total number of documents attached:

SECTION 6 - Consent & Signature

You must check both boxes below to provide consent:

I confirm that all information provided is accurate to the best of my knowledge.
I understand that the information shared will be kept confidential and used soley by the Motorcycle Sanat review committee for the purpose of evaluating this nomination.

Signature of Nominator or Self-Nominee (typed)

Date

Motorcycle Santa Medical Hardship Support Program