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Your First Name*

Your Last Name*

Your Age*

Relationship to Nominee

Your Phone Number*

Your Email*

Mom's Contact Details

Mom's First Name*

Mom's Last Name*

Mom's Age*

Mom's City*

Mom's Phone*

Mom's Email Address (if known)

Tell Us Her Story

Don't worry about making it perfect — authenticity matters far more than production quality.

1. Tell us about your mom.*

2. Why are you nominating her?*

3. What sacrifices has she made for your family?*

4. What challenges has she overcome during her life?*

5. When was the last time she truly did something just for herself?*

6. How has motherhood or life affected her confidence?*

7. What would this 12-month journey mean to her?*

If Other, Please Specify

9. Finish this sentence: "My mom deserves this because..."*

10. Tell us something special about your mom that most people don't know.*

11. Why would people be inspired by following her journey?*

File Imports

Please record a 60–90 second video on your phone, answering:*

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Max. file size: 50 MB.

Tell us your name Introduce your mom Why is she your hero? What sacrifices has she made for your family? Why does she deserve this opportunity? What would it mean to watch her regain confidence? Why do you believe her story could inspire other women? Don't worry about making it perfect. Speak from the heart.

Photo Submission*

Drop files here or

Max. file size: 50 MB.

Please include: A recent photo of your mom A favorite photo of you and your mom together Optional family photos

How Did You Hear About Us?

If Other, Please Specify

Permission

I understand that if my mom is selected, she will be asked to participate in photos, videos, interviews, and social media throughout her 12-month transformation journey.

Signature (Type Full Name)*

Date*

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