THE INDIANA
FACE OF BREAST CANCER
NOMINATION
FORM
The Indiana Face of Breast Cancer is a traveling exhibit that has been on display throughout North Central Indiana since the Fall of 1997. We are looking for Hoosier women and men whose lives tell the story of struggling with breast cancer. If you want to nominate yourself or someone else for possible inclusion in the exhibit, please complete this form.
Photographic Information: You may submit up to three different photos of the nominee. Please choose a picture that is as clear and as sharp as possible for reproductive quality assurance.
Subject matter should highlight important aspects of the nominee’s life. The photo should capture and convey to the viewers the essence of the nominee’s life: her/his family, friends, joys or sorrows, or a special time in the nominee’s life.
Please mark each photo submitted with the nominee’s name. All photos will be treated with care. If you want the photos to be returned, please include a stamped self-addressed envelope. The committee is not responsible for any damage that may occur during mailing.
Your total response should not exceed 500
words.
1. Name
of nominee _________________________________________________________
2. Is the nominee a breast
cancer survivor? ______________________________________
If the answer to number 2 is yes, please answer (a) and (b)
below. If the answer is no,
please proceed to number 3.
a. How
old is the nominee? ________________________________________________
b. What
year was the breast cancer diagnosed? ______________________________
3. Is the nominee deceased? ___________________________________________________
If the answer to number 3 is yes, please
answer (a) and (b) below. If the answer
is no,
please proceed to number 4.
a. Year of death ______________________ Age at death _____________________
b. Year
of breast cancer diagnosis __________________________________________
4. Provide a brief statement
that captures the essence of the nominee’s life.
5. Describe why the nominee’s picture should
be part of this exhibit. Please include
any additional biographical information about the nominee that you believe is
important
for the committee to consider, such as family information and community
involvement.
Attach additional sheets as needed.
6. Optional.
Provide a short quote by the nominee.
7. Name and relationship/title of person
submitting nomination
____________________________________________________________
Address ___________________________________________________
City, State, and Zip __________________________________________
Phone number, including area code ____________________________
NOMINATIONS MUST BE RETURNED NO LATER THAN MAY 1, 1999.
SEND COMPLETED FORM AND PHOTOS TO:
BREAST CANCER TODAY SURVIVORS' GROUP
WEST LAFAYETTE,
IN 47906 WEST
LAFAYETTE, IN 47906
Questions? Call CLAUDIA KRUGGEL
at 765-743-6485 or BARBARA WHITE at 765-463-6168.
RELEASE FORM
_____________________________________
(print or type name of nominee)
A) FOR NOMINEES WHO ARE LIVING
I, ______________________________________, give permission without restrictions to the
(print or type nominee’s name here)
Breast Cancer Today Survivors'
Group to use my photographs and information submitted for
or by me for educational and promotional use for The Indiana Face of Breast Cancer
exhibit.
_____________________________________
(Nominee’s signature of permission)
B) FOR NOMINEES WHO ARE DECEASED
I, ______________________________________, have the authority vested in me to grant
(print or type nominator’s name here)
permission to the Breast
Cancer Today Survivors' Group to use photographs and information
submitted on behalf of ______________________________________ for educational
and
(print or type name of deceased)
promotional use for The Indiana Face of Breast Cancer exhibit.
_____________________________________
(Nominator’s signature of permission)