Honored Hero Application - New Jersey Region

Thank you for your interest in the Honored Hero Program!

An Honored Hero is an indvidual who is currently undergoing treatment, or who is in remission from a blood cancer. Our Honored Heroes share their stories, spread awareness, serve as an inspiration and provide support to The Leukemia & Lymphoma Society (LLS).

Name of Submitter *

Submitter's Email Address

Relationship to Honored Hero *

Honored Hero Name *

Preferred Pronouns

Race/ Ethnicity

Preferred Language *

Honored Hero Email Address

Phone Number *

Address *

City *

State *

Zip Code *

County *

Birthdate: Month

Day

Year

Diagnosis *

Date of Diagnosis * +

Age of Diagnosis *

Date of Remission *if applicable +

Currently in Treatment? *

Name of Treatment Facility *

What is your last known school? Elementary, Middle, High School, College?

In this section, please tell us a little bit about yourself or your loved one (e.g. your cancer journey, hobbies, occupation, favorite pet – anything that describes you or your loved one’s personality and that can help our team get to know you!) Feel free to be as specific as you'd like, but please limit your response to no more than 300 words.

0/300 words

Please attach a photo of yourself or your loved one to this application.

I am interested in being an Honored Hero for:

Thank you so much for applying to the Honored Hero Program! Our committee will assess all applications and an LLS Staff Member will contact you if selected. If you have any questions, comments, or concerns, please do not hesitate to contact Stacy Kreizman at (908) 956-6608 or at Stacy.Kreizman@lls.org!