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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
Country
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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
Country



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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.