2019 Annual Captain A Honoree’s Form

Simple rules to be a Captain A – Fighting the War on Cancer Honoree;

  • Candidate must be a survivor or posthumous
  • Candidate must be willing to share their story at our Captain A We will love you Through it in October and at the Puerto Rico Gala
  • The nominator must fill out the below form for candidate consideration.
  • Nominations must be submitted by June 5, 2019.

Please remember this is just a nomination, Captain A – Fighting the War on Cancer Committee will review each submission, and the nominees will be contacted directly, they will be announced by July 20, 2019.

All honorees will be honored on our Annual Captain A We will love you Through it on Thursday, October 17, 2019, and our first ever Puerto Rico Gala on August 17, 2019.

Nominator Information
First Name
Last Name
Address
Zip Code
City
Home
Email
Email Address
Cell
Preferred Contact Method (check all that apply):
Nominee Information
Nominee First name:
Last Name
Nominee Address
Nominee City
Nominee Zip Code
Nominee Date of Birth
Nominee Photo
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Nominee Phone Number:
Is the nominee a
  • - select a option -
  • Survivor
  • Posthumous
If a survivor, are they in treatment
  • - select a option -
  • Yes
  • No
Type (s) of cancer :
Why do you feel that the nominee should be highlighted at the 2018 Captain A We will love you Through it Diner?
Is there anything else we should know about the nominee?
This year’s nomination deadline is Sunday, August 12th, 2018
Submit