Magic Moments Nomination Form

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Your First and Last Name

Street Address/City/State

Phone Number

Email Address

Nominee's First and Last Name

Nominee's Street Address/City/State

Nominee's Phone Number

Family living at this address:

^{Names of family members, including children (if any), and their ages}

Reference Name & Phone

^{Someone other than the nominator and not living in the home}

Detailed description of the nominee’s story along with their special need or wish

^{We will not provide a vehicle, debt reduction, or utility payments and the nominee must live in Lancaster County}

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