B Kind for the Holidays Questionnaire B the Difference

Step 1: Sign the General Release form here. This allows B the Difference the use of your name and provided photo. A legal guardian will have to fill out and sign on behalf of a minor (under the age of 18).

Step 2: Complete and submit the form below.

Step 3: A member of our team will get in touch with you to purchase your holiday gift card.

Please Tell Us About Yourself
To be filled out by a parent or guardian if you are a minor.
Name*
First Last
Birthdate*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Please provide a valid email. This is the email your $250 electronic gift card will be sent to.
Phone*
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 additional family members living with you.*
Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
Name
First Last
Date of Birth
MM slash DD slash YYYY
Add family member
- Add family member
Name
First Last
Date of Birth
MM slash DD slash YYYY
Add family member 2
- Add family member
Name
First Last
Date of Birth
MM slash DD slash YYYY
Do any of your family members also have NF? If so, who?*
B Kind for the Holidays
What does this B Kind for the Holidays gift mean to you?*
Please provide a quote that we can share with our Board of Directors and donors who made this gift possible.
Please choose your preferred gift card option*
Your gift card will be delivered electronically by email.
Family/Individual Photo
Please upload a family photo for use on the B the Difference website.
Post Image*
Maximum file size 2MG
Accepted file types: jpg, jpeg, png, gif.
I'd like to B in the know!
- Sign me up for B the Difference emails

Please Tell Us About Yourself

Additional Family Members

B Kind for the Holidays

Family/Individual Photo