Nominate Someone - Save The Cups

Apply for Assistance

Nominee Information

Nominee Name

Nominee Phone

Nominee Email

Nominee Age

Where do they live, City and State?

Your Information

Your Name

Your Phone Number

Your Email

Medical Information

When were they diagnosed with breast cancer?

Is this their first occurrence? Has it metastasized?

What is their official diagnosis? Please include Stage

Where are they in the treatment process?

Have they had any recent hospitalizations? Please provide date

About Your Nomination

Tell us about the person you are nominating and why you are nominating them.

Do you know for certain this person has outstanding medical bills?

Do they have medical insurance?

Additional Information

How did you hear about Save the Cups?

Have they been to a Swig location? If so, which locations?

Is there anything else you would like to share?

Upload photos or videos

Click to upload or drag and drop

At least one photo or video is required

image/jpeg, image/png, image/webp, video/mp4, video/quicktime up to 25 MB (max 5 files)

Legal Disclosure: By submitting this form, you confirm the information provided is accurate and consent to its use by Swig for the sole purpose of administering the Save the Cups program. If nominating someone else, you represent that you have their permission to share their personal and medical information. Submission does not guarantee assistance.