United Way of Central Illinois Logo
Information
Christmas Wish Nomination Form
Your Information
First Name
required
Last Name
required
Mobile Number
required
Email
required
Address
required
City
required
State
required
Your State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
required
Best time to contact you?
required
Nomination Information
If selected your nominee will be notified of your nomination
Who would you like to nominate? (First and Last Name)
required
Nominee Address
City:
required
State:
required
Zip Code:
Nominee Phone Number (including area code)
required
Tell us about the Good Deeds that the nominee has done or why this individual/family deserves to have a Christmas Wish fullfilled?
required
255 character limit
0
/ 255
Tell us about the nominee's SPECIFIC need (Christmas Dinner for 4, haircut, school supplies for ##, etc...)
required
255 character limit
0
/ 255
Additional Comments/Information
255 character limit
0
/ 255
Best time to contact nominee?
required
Google ReCaptcha Response
SUBMIT
Processing...