Refer a B Happy Nominee

Please complete the following form to the best of your knowledge. Thorough and detailed information will assist immensely. Please note that this is the first step in the B Happy selection process; it is not confirmation that your referral will be selected for a trip. The information you provide will be received, and a B the Difference team member will contact you.

All nominations are confidential.

B Happy Referral

Your Information
Your Name*
First Last
Your Email*
Your Phone*
Relationship to Individual*
Self-referrals and referrals from immediate family members are not eligible.
Nominee Information
Name of Nominee*
First Last
Gender of Nominee*
As it appears on photo ID (if applicable)
Age of Nominee*
Must be between the ages 13 to 30.
Hometown/State*
Nominee Contact Information (parent of guardian if under 18)
Parent/Guardian Name*
First Last
Email*
Phone*
What inspired you to recommend this individual?*
Has this individual been granted a Make-A-Wish? If so, when?*
Please add any additional information you feel we may need to know about this individual for our selection process. (Optional)
HIPPA Disclaimer*
Personal contact and medical information is protected by HIPPA laws. This family has given approval to share contact and medical information with B The Difference
- Yes
- No
How did you hear about B the Difference? (Please provide as much detail as possible)*
Comments
This field is for validation purposes and should be left unchanged.

Refer a B Happy Nominee

B Happy Referral

Your Information

Nominee Information

Nominee Contact Information (parent of guardian if under 18)