'Take The Leap Champion' - Nomination Form

1
Your Full Name* This field is required.
First Name
Last Name
2
Your Email Address* This field is required.
example@example.com
3
Name of Champion You Are Nominating* This field is required.
First Name
Last Name
4
Nominee's Email Address (if known)
example@example.com
5
What is your relationship to the Nominee?* This field is required.
Please Select
Please Select
Family Member
Friend
Colleague
Community Member
Other
6
Briefly explain why you are nominating this person to be a 'Take The Leap Champion'* This field is required.Tell us your ‘what drives me’ story (150-300 words)
Huge
Large
Normal
Small
Ok
Ok
7
Willingness to go on Camera (Nominee)* This field is required.If selected as a monthly ‘Take The Leap Champion’, the Nominee agrees to participate in video content (on-camera interview) ahead of the Vhi Women’s Mini Marathon.
Please Select
Please Select
Yes
No
8
Full, Clean Driving License (Nominee)* This field is required.The overall winner will receive the use of a brand-new 262-registration Leapmotor for 6 months, from July-Dec 2026.
Please Select
Please Select
Yes
No
9
I confirm that the information provided is accurate and I consent to its use for nomination purposes.* This field is required.
Should be Empty: