Please tell us about your hero using the form below. Click here for more information regarding “District 5 Heroes”. THE NOMINATION PERIOD WILL END AT 1159PM ON 11/7/15.
1. Your Name (required)
2. Contact Email Address (required)
3. Contact Phone Number (optional)
4. Your Heroes Name (required)
5. Your Heroes Address (required)
6. Your Heroes Phone Number or Email Address (required)
7. How did you hear about District 5 Heroes? (optional)
This question is used to prevent computers from submitting spam. What color is a banana?
8. In 500 words or less, please describe your hero, including why you think they should be recognized? (required).
You may copy and paste your story OR type it.
The box above will expand to fit your text. You may also manually expand the box by dragging the lower-right corner of the box.
9. We plan to post your story on this web site and our Facebook page. Please select "Yes" if you agree to the following so we can use the photo you uploaded: I hereby consent to and authorize the use and reproduction, in print or electronic format by District 5 United or anyone authorized by District 5 United, of any and all stories and photographs I have provide for any publicity purpose without compensation. I hereby acknowledge that I have read and understood the terms of this release.
You will receive a confirmation email and a separate email with a link to a web page with your story. Click the Send button below to submit your story.
If you encounter any difficulties or if you don't use email, please contact email@example.com or 408-910-5966.
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