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Nominate
Your Contact Information (As the Nominator)

First Name
Last Name

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code
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Nominee's Contact Information (The Patient)

First Name
Last Name

Address Line 1
Address Line 2
City
State/Province
ZIP/Postal Code



*

If we should not call Nominee directly, please provide contact information for an alternate person.
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Please let us know the story behind the nomination; why you feel that you, your friend/loved one(s) and their caregivers would be a good candidate for a sail with us on Lake Champlain.