Complete the form below for a Stage 4 Breast Cancer candidate you would like to nominate for a 2017 vacation experience. Nominations close May 1, 2017. LESLIE'S WEEK will confirm receipt of the form and notify you of the results on or before May 15, 2017.

6"x9" Post Card Template
Nominee's Name *
Nominee's Name
PLEASE BE SURE TO COMPLETE ALL INFORMATION IN EACH BLOCK OR THE NOMINATION WILL BE CONSIDERED VOID.

NOMINATIONS FOR 2017 OPEN ON JANUARY 15


“The simplest acts of kindness are by far more powerful then a thousand heads bowing in prayer.”

- Mahatma Gandhi