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LLS NE Honored Hero Information
The Nebraska Chapter | 11840 Nicholas St. Suite 215 | Omaha, NE 68154 | (402) 344-2242
First Name
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Last Name
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Date of Birth
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If under 18 years old:
Parent/Guardian First Name
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Parent/Guardian Last Name
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Street Address
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Address Line 2
City
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State
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Zip Code
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Phone Number
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Email Address
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T-Shirt Size
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XS
S
M
L
XL
XXL
Youth XS
Youth S
Youth M
Youth L
Youth XL
Diagnosis
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Date of Diagnosis
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Please provide a description of your journey through treatment:
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Have you previously been involved with LLS? If so, how did you get involved?
Please write a brief description of your current interests/hobbies and/or a fun fact about yourself to share on our Honored Hero Poster
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Please upload up to 3 photos, including one photo that would serve well as a headshot.
How involved would you like to be? I am willing to:
Attend local events
Write cards or letters
Speak for media
Help with award presentations
Advocacy
Volunteering
List any other ways you would like to be involved:
Enter the word in the image
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