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December to Remember nomination

Your first & last name*

Phone*

Email*

Instagram username

Name of the person/ family you are nominating*

Does this person live in the Plant City area?*

Yes

No

Please tell us why you are nominating this person*

What items do you feel would help them this holiday season?*

Does this person have children?*

Yes

No

If so, please provide names and ages of children.

If children, what items do you feel would help them this holiday season?

Are you able to join Ali for surprising the family?*

Yes

No

Do you give permission to be filmed?*

Yes

No

What is your Christmas wish for this person this holiday season?

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