SLC - Nomination

Use the following form to send us information about the family you wish to
nominate to receive support from the Samantha Fund. Fill in as much
information as you can. If you c ontact u s by other means, use the form as a
guideline for the information we need.

SAMANTHA LORENE CALAFIORE MEMORIAL FUND, INC.

Your Contact Information:

Your name:*

Your email address:*

Your phone number:

Nominee's Contact Information:

Nominee's Name:

Nominee's address:

Nominee's email address:

Nominee's phone number:

Nominee Details:* (age, other children/siblings, parents working, travel
for treatment, diagnosis).

Additional Information:

* This information is required.