Nomination Form
Due to the volume of requests, we simply can't reply to every wish. Only one nominee will annually receive a free week of accommodation at Wyndham Durango.
- A Wyndham Timeshare Resort in Colorado -
“Anna’s Journey” is not a traditional non-profit organization. “Anna’s Journey” receives the sponsorship for this Vacation Resort stay from a private business individual who wishes to stay anonymous.
Once a nominee is selected, (must be 21 years or older and have a credit card to check in with), she will be notified by e-mail & receive her Vacation Guest Certificate which will be used to Check In with. The selected nominee will personally be responsible for any and all vacation related expenses including but not limited to transportation, food and entertainment during their stay.
The SELECTED NOMINEE will receive ONE week of accommodation in a One Bedroom Unit
(sleeps up to 4), with a small kitchen and a Pull-Out Sofa in the living room area.
Name:____________________________________________ Date of Application________________________
First Last
Home Address: ____________________________________________________________________________________
Street City State Zip
Telephone #: _____________________________________________________________________________________
Home Cellular Other
Email address: ___________________________________________________________________________________
Your relationship to nominee:_______________________________________________________________________
Contact Information for the nominee
Name___________________________________________________________________________________________
First Last
Home Address: ___________________________________________________________________________________
Street City State Zip
Telephone #: _____________________________________________________________________________________
Home Cellular Other
Email address: __________________________________________________________
Occupation of Nominee: _______________________________________________________Current age: ____________
Marital status: □ Single □ Married □ Separated □ Divorced □ Widowed □ Other
Race/Ethnicity: □ White/Non-Hispanic □ Hispanic/Latino □ Black/African American □ Asian
□ American Indian/Alaska Native □ Native Hawaiian/Pacific Islander □ Other
Citizenship: □ US Citizen □ Permanent Resident □ Other
Number of children and ages: (1) ________ (2) ________ (3) _________(4) _________
Date of Initial Diagnosis: ____________
Copy of Dr’s confirmation letter included: _______(Y) _______(N)
Stage of Breast Cancer at Initial Diagnosis: _______________ Current Stage: ________________
Check with a yes
___ I hereby commit to provide 2 photographs to be used on Anna K. Leon’s website for the purpose of showing my vacation -
one of me individually and one of me enjoying a fun vacation activity with my family or friends.
___ I commit to write a short paragraph (consisting of 75 – 100 words), describing what this vacation meant to me.
Medical Journey and why I (nominee) deserve this vacation stay:
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
General Info:
Fact: Today, many honest hardworking American families struggle to make ends meet. Some, through no fault of their own, find themselves in serious financial trouble and never take the time out to relax and just put their feet up for a much needed vacation. Many of these hardworking families include moms with breast cancer.
The motive behind this gift is to allow one woman per year to enjoy a “White Christmas” vacation in Durango, Colorado.
This is a gift to the selected nominee of ONE WEEK Resort vacation to be enjoyed during Christmas. Please check the website for Durango Resort info & directions: (https://www.wyndhamvacationresorts.com/ffr/resort/details.do?id=0042)
Please read and follow the Nomination Instructions stated below:
Print out this entire Nomination Form
Complete Nomination Form by hand
Scan and email Nomination Form to: annakleon2014@gmail.com
We will only receive nominations until the October 1, 2014 midnight.
The successful nominee will be notified by email on or before October 15, 2014
We ultimately HOPE that this will act as a small catalyst and inspire other people to do similar acts of kindness.
We truly rely on your honesty and integrity - a fraudulent request/ nomination will take this opportunity away from a deserving individual who legitimately qualifies for the assistance.
CHECK-IN/CHECK -OUT PROCEDURE:
At check in, Wyndham (the resort) will require a credit card imprint to cover any negligent damage and/or personal charges which you may incur during your stay. Please note - Wyndham will only issue guest certificates and allow check in to persons age 21 and older.
1. Check-In. Check-in time is at 4pm on Sunday December 21, 2014. No early check-ins.
2. Check-Out. Check-out time is at 10am on Sunday December 28, 2014. Late check-outs will result in a late check-out fee be charged to the guest’s credit card held on file at the resort.
Use of Premises: Vacationers will comply with all local laws, ordinances and community rules regarding the use of the premises. Vacationers will comply with all Wyndham Durango Resort’s set rules.
How did you hear about us? □ Family Member □ Friend X Physician/Nurse/Social Worker
□ Our brochure □ Internet (e.g., Google, Facebook, etc.) □ News Media (magazine, newspaper, radio, TV) □ Other
