B Kind Questionnaire

Please Tell Us About Yourself

To be filled out by a parent or guardian if you are a minor.

Phone*

Email*

Do you have NF1, NF2, or Schwannomatosis?*

At what age were you diagnosed with NF?*

Tell us about your NF story (what surgeries and/or treatments have you had, struggles since your diagnosis etc.).*

Additional Family Members

Please list the names and ages of additional family members living with you.*

Do any of your family members also have NF? If so, who?*

Requested B Kind Assistance Details

Clinical Trial Information

If other, please specify

Please provide the following details:

confirmation number, airline, dates etc.

If your flight is NOT booked, please provide the following:

departure airport, arrival airport, dates and travel times.

Please provide the following information:

Starting location (city/state or address), destination location (city/state or address), estimated round-trip mileage, if necessary.

If other, please specify

Please provide the following information, if applicable

Departure city/station/address, arrival city/station/address, preferred travel dates/times

Please provide the following information:

hotel/lodging details ie. reservation number, hotel details, arrival/departure date etc.

Please provide the following information:

Hotel/lodging preference, # of rooms, # of beds, arrival and departure dates etc.

Please provide the following for every person accompanying you:

full legal name, gender, and birthdate

Food Assistance Details

Please provide your top three preferences for grocery stores.

We are unable to provide gift cards to small regional stores, and retailers like Trader Joe's and Aldi. Please list a bigger box store like Walmart, Kroger, Meijer, Target, Whole Foods, Publix etc.

Medical/Travel Assistance Details

Please explain in detail what assistance you are requesting ie. medical bill pay, medical equipment, upcoming appointment etc.

If you are requesting assistance for medical devices, please list them, share a link, or upload a photo.

Please share the estimated cost of the medical services or medical bills requested. You can upload a bill, invoice, or more information below.

File

Max. file size: 7 GB.

If requesting medical bill pay, please share who we contact to submit a payment on your behalf?

A number to call, a website to pay, a contact number for a clinic/hospital, etc.

Educational Assistance Details

Please share a link or list specific educational products that you are requesting.

Rent Assistance Details

Please share more details about your rent

The amount of rent you pay, when your rent is due, how you pay your rent ie. Zelle, Venmo, check, online portal etc.

Please share who we contact to submit a rent payment on your behalf?

Your landlord's name and/or property management name, and phone number and/or email to contact etc.

If granted, what will this B Kind relief mean to your family?*

Family/Individual Photo

Please upload a photo for use on the B the Difference website.*

Max. file size: 15 MB.

Thank you!

Anything else you'd like to share?

Thank you for filling out our questionnaire. We appreciate your time and are grateful for you. We sometimes share these answers with our Board members and on social media to promote our B Kind program. Your thoughts could benefit others and are greatly appreciated.