District 5 United!
Community Working Together
Please tell us about your hero using the form below. Click here for more information regarding “District 5 Heroes”.
1. Your Name (required)
2. Contact Email Address (required)
3. Contact Phone Number (optional)
4. Your Heroes Name (required)
5. Your Heroes Address (optional)
6. Who is Your Hero and why? (required). You may upload a file or enter your Hero's story in the text box below.
Upload your story....
...copy and paste your story here (OR type it now)...
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.
7. All heroes will receive a certificate. Should your hero also be considered for special recognition, including a plaque and pin, at the "District 5 Heroes" event on June 30th? (required)
8. You may upload a photo of your hero (optional). This photo will be displayed on the "District 5 Heroes" web page for your story.
9. We plan to post your story and any photos 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 provided for any publicity purpose without compensation. I hereby acknowledge that I have read and understood the terms of this release.
This question is used to prevent computers from submitting spam. What color is a banana?
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 and any photos
If you encounter any difficulties or if you don't use email, please contact firstname.lastname@example.org or 408-910-5966.