B Kind Questionnaire

"*" indicates required fields

Please Tell Us About Yourself

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

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Birthdate*

Month

Day

Year

Phone*

Email*

Stay in the Loop!

I'd like to be first in the know. Please sign me up for B the Difference emails.

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

B Kind provides relief in the form of food assistance, and medical or education needs. Which area of relief will most benefit your family and why?*

Food Assistance

Medical/Travel Assistance

Educational Assistance

Rent Assistantce

Is requested assistance to help you participate in a Clinical Trial or travel to the NIH?*

Yes

Clinical Trial Information

What method of transportation are you taking or plan to take to participate in the clinical trial?*

Fly

Drive

Public transportation or Rideshare service (Uber, Lyft etc.)

Other

If other, please specify

Is your flight already booked?

Yes

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.

Type of transportation

Bus

Train

Rideshare ie. Uber/Lyft

Other

If other, please specify

Please provide the following information, if applicable

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

Are you requesting lodging/accommodation for your travel?

Yes

Is your lodging/accommodation already booked?

Yes

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.

Is someone traveling with you?*

Yes

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.

If you chose food assistance, please let us know your delivery preference for gift cards:

E-gift card: sent to the email listed above, and delivered immediately. Can be used in store and online.

Physical gift card: sent to the mailing address listed above. Can be used in store and online. Please anticipate up to 10 days shipping time.

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.

Release Form

Instructions
Every family member aged 18 and up must sign the release form.

Grant
For consideration which I acknowledge, I irrevocably grant to B the Difference and B the Difference’s assigns, licensees, and successors the right to use my image, name, and information from the NF Summit Scholarship application in all forms and media, including composite or modified representations for all purposes, including advertising, trade, or any commercial purpose throughout the world and in perpetuity. I waive the right to inspect or approve versions of my image used for publication or the written copy that may be used in connection with the images.

Release
I release B the Difference and B the Difference’s assigns, licensees, and successors from any claims that may arise regarding the use of my image, including any claims of defamation, invasion of privacy, or infringement of moral rights, rights of publicity, or copyright. B the Difference is permitted, although not obligated, to include my name as a credit in connection with the image.

B the Difference is not obligated to utilize any of the rights granted in this Agreement. This Agreement expresses the complete understanding of the parties.

Signature*

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.