Nomination Form - Heroes of Hope

To nominate a Hero, please complete all information below. For tips on filling out the form, please click here.

Nominee's Information:

First Name Last Name

Male Female

Date of Birth

Street Address Line 1 Street Address Line 2

City State 5-Digit ZIP Code

Phone Number Email Address

Nominator's Information:

First Name Last Name Relationship

Street Address Line 1 Street Address Line 2

City State 5-Digit ZIP Code

Phone Number Email Address

Describe how the nominee meets the following nomination criteria:
If additional information is provided, only two additional pages (1,000 words total) will be accepted.

1. Attitude: Describe the nominee’s attitude to approaching daily life, pursuing his/her dreams and accepting CF.

2. CF health routine: Describe the nominee’s daily health routine regimen in detail (i.e., frequency; types of oral, inhaled, and I.V. medicines; airway clearance; number of hospitalizations; other conditions; etc.). Include information about his/her compliance with the regimen.

3. Determination: How has the nominee exhibited strength, resilience, and responsibility in meeting the challenges of CF?

4. Service: Describe the nominee’s participation in community activities (athletics, church, volunteer work, school, music, etc.). How is he/she a role model to others?

5. Achievement: What are some of the nominee’s skills or talents? Has he/she been recognized for any special achievements?

6. Additional information: Is there anything else that you would like to say about the nominee that sets him/her apart?

Thank you for your interest in the Heroes of Hope^™ Living with CF program. This nomination form will be reviewed by the Heroes of Hope Living with CF panel, and if your nominee is chosen, he or she will be notified about the next steps, which include extending the program permission to contact the nominee’s healthcare provider to verify that he/she has cystic fibrosis. If you would like to inquire into the status of your form, please call (212) 257-6995 or email mweiss@wcgworld.com.

This nomination form will remain active for 12 months. If the nominee has not been chosen within 12 months from the original submission date, the candidate’s name and nomination must be resubmitted for consideration. Signing the nomination form gives the Heroes of Hope Living with CF program the right to use the nominee’s likeness in media, online promotional activities, etc., once he or she is selected.

Statement of Use: Any medical information you provide will be held in strict confidence by the Heroes of Hope Living with CF program panel members and Genentech USA, Inc. Any information you provide will be utilized only for the purposes of evaluating your nomination and communicating with you regarding your nomination and/or selection. We will not sell your information or share your information with any other company or organization aside from the vendors we have hired to manage communications with you regarding the Heroes of Hope Living with CF program. If you have any questions, please refer to our Privacy Statement at www.pulmozyme.com.