B Kind for the Holidays Referral

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Your Information

Your Name*

First Last

Your Email*

Your Phone*

Candidate Information

Name*

First Last

Email*

Provide guardian email if minor

Phone Number*

Provide guardian phone if minor

Age of Candidate*

Gender of Candidate*

As it appears on photo ID (if applicable)

Hometown/State*

Parent/Guardian Name

If the candidate is under 18.

Parent/Guardian Phone Number

Parent/Guardian Email

Name of family member(s) with NF.*

Please share what inspired you to nominate this family/individual to B Kind for the Holidays.*

What is your relationship to the candidate?*

ie. social worker, physician, NF community member etc. Self-referrals and referrals from family members are not accepted.

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

How did you hear about B the Difference and our B Kind for the Holidays program?*

I'd like to B in the know!

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