B Kind Questionnaire

Please fill out the form below and sign the release form here.

"*" 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?*

B Kind Relief

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?*

If you chose food assistance, please provide your top three preferences for grocery stores.

We are unable to provide gift cards to small regional stores. 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.

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.