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)
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 your interest, hobbies, and passions? Do you still participate in any of these today?
What were your past occupations, if any?
What have you done to give back to others? What volunteer work do you do now or have you done in the past?
What is something you still wish you could do but now are unable to?
What is something you always wanted to do but have never had an opportunity to do?
Are you a military veteran?
- Yes
- No
Are you a legal resident or citizen of the U.S.A.?
- Yes
- No
Have you ever been convicted of a crime?
- Yes
- No
Are there any physical or cognitive impairments that we would need to plan for in helping you? (ie, wheelchairs, oxygen, caregiver, dementia, etc.)

Project Description
Describe the project in detail.
Why would this be important to you?
What will you experience (mentally, emotionally, physically, or spiritually) as a result of the project?
How would this enrich your life and the lives of those around you?
Why are you unable to fulfill this wish on your own?
Have you ever done something like this before?
Are you capable of completing this project (what challenges might you encounter)?
Disclaimer
By submitting this nomination form, I acknowledge that acceptance of this nomination by The ELF Project does not constitute a commitment by The ELF Project to fulfill this request. If the nomination moves to the next stage, an ELF Project 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 The ELF Project in a timely manner should any information provided in this application change.

Recipient Information