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.

 

NOMINEE’S BIOGRAPHICAL INFORMATION  PLEASE PRINT ALL RESPONSES

Your total response should not exceed 500 words.

 

1.     Name of nominee                  _________________________________________________________

 

        Nominee’s Address         _______________________________________________________

 

        Nominee’s City                      ___________________________________________________________

 

        Nominee’s Phone number, including area code        _______________________________

 

        Nominee’s Occupation        _____________________________________________________

 

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

C/O            CLAUDIA KRUGGEL            OR            BARBARA WHITE

            1385 KINGSWOOD RD. N.                    2108 NORTH SALISBURY STREET

            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)