Contact 1 — Michael L. DiTore Small Moments Foundation

Please use this form to submit your nomination of an eligible family from the Greater Philadelphia Area.

Nominees should be families with children (18 and under) who’ve lost a parent or sibling to cancer in the last 24 months.

Nominator

Please provide information for the person nominating this child to Small Moments.

First Name

Last Name

Relationship to Nominee

Email

Phone

(###)

###

####

Child 1

Please provide information for the child or children being nominated.

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 2

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 3

First Name

Last Name

Date of Birth

MM

DD

YYYY

Child 4

First Name

Last Name

Date of Birth

MM

DD

YYYY

Guardian

Please provide information for the primary guardian of the child or children listed above.

First Name

Last Name

Address

Please provide the primary address of the family you are nominating in Montgomery County, PA.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Guardian's Phone

(###)

###

####

Guardian's Email

What is the relationship between this child (these children) and the deceased loved one?

Mother

Father

Sibling

Other

Date of Death

MM

DD

YYYY

Nomination details

Please tell us more about the child/children you are nominating. What do they like? What excites them? What are their hobbies? Tell us everything!!!

NOMINATIONS ARE OPEN!!!!!!!