I acknowledge that I am 18 years of age or older. I have read and understand the rules of this drawing. I DO NOT live in AL, KS, HI or UT. I understand that if I purchase a ticket and my address and driver’s license are from one of the excluded states listed above, the ticket price will be refunded minus a processing fee charge.

This is a test page. Nominations submitted using a form from this page will NOT be considered.

First Name*
Last Name*
Address
City*
State*
Zip
Phone*
Email*
Date of Birth "mm/dd/yyyy" (must be 18 or older) *
Charity*
What City is the Charity located in?*
What State is the Charity located in?*
Charity Website (if known)
Charity Mission Statement (if known)
Charity Contact Name*
Charity Phone Number (if known)
Charity Email (if known)
Is This a Parent/Teacher Organization
In 148 words or less, describe how this organization supports K-12 public education. Please include specific programs when possible.*
In 148 words or less, please share why this charity logo should be featured on Jimmie’s helmet and why it is important to you. *
How You Heard