Temporary B Kind Referral B the Difference

Please note, this is a temporary form that only you have access to. As soon as B Kind is accepting new referrals again, please use our main referral form here.

Your Information
Your Name*
First Last
Your Email*
Your Phone*
Relationship to individual*
Self-referrals and referrals from immediate family members are not eligible.
Candidate Information
Name*
First Last
Gender*
As it appears on photo ID (if applicable)
Age of Nominee*
Hometown/State*
Email*
Phone*
Parent/Guardian Name
If under 18.
First Last
Parent/Guardian Email
Parent/Guardian Phone
Please describe in detail how B Kind assistance would benefit this individual/family?*
The B Kind Program provides relief with food assistance and medical and educational needs. Which category of relief would this family/individual benefit from? (Please be specific)*
Have you identified any other forms of assistance that we could provide to the NF community?
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
- No
How did you hear about B the Difference?*

Your Information

Candidate Information