Postmarked with Love Recipient Nomination

Recipient Nomination Form

Thank you for your desire to nominate an individual with FA, caregiver, or family member to be a recipient of a little extra love and support as they navigate a challenging time.

Please complete this form to the best of your ability. No identifying information provided about the recipient will be shared with volunteers. Hobbies and very general information about their situation (e.g, major medical even, new diagnosis) may be shared with volunteers. Your name will also remain anonymous to the card recipient.

It is helpful for us if you are able to provide contact information for the person you are nominating.

Note: We will mail cards out in batches quarterly to recipients. Please ensure to nominate your individual by one of the following dates.

March 30th, 2022
June 29th, 2022
September 28th, 2022

Please contact Rosie Holcomb at Rosie@fanconi.org if you have any questions.

Question Title

* 1. Your contact information

First Name *

Last name *

Address

City/Town *

State/Province *

ZIP/Postal Code

Country *

Email Address *

Phone Number *

Question Title

* 2. Tell us a little bit about who you are

Person with FA

Caregiver or guardian to someone with FA

Friend of a person or family impacted by FA

Family member of someone with FA (other than primary guardian)

Professional who works with those impacted by FA (medical professional, researcher, support organization, psychosocial support, etc.)

Donor

Other (please specify)

Question Title

* 3. Who would you like to nominate?
(if nominating a minor, please list minor's first/last name and include guardian's name and contact information if known)

First name *

Last name *

Guardian's name (if nominating a minor)

Street Address

City/Town

State/Province

ZIP/Postal Code

Country *

Email Address

Phone Number

Question Title

* 4. The person you are nominating is...
(select multiple if more than one applies)

An individual with FA

Caregiver/parent/primary guardian

Caregiver/significant other, partner, or spouse

Sibling of an individual with FA

Bereaved or grieving the loss of an individual with FA

Extended family member of an individual with FA

Other (please specify the recipients connection to FA)

Question Title

* 5. Card recipient age group

Under 18

18-29

30-39

40-49

50+

Other: If under 18, please specify age if known.
If you do not know the age of the person you are nominating, type UNKNOWN.

Question Title

* 6. Do you know the card recipient's preferred gender pronoun?

She/her/hers

He/him/his

They/them/their

Prefer not to say

Unknown

Other (please specify if known)

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* 7. Card recipients primary language?

English

Spanish

Unknown

Other (please specify language if known)

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* 8. Is the person you are nominating navigating any of the following difficulties?

Recent FA diagnosis

Transplant

Cancer diagnosis

Major surgery

Loss of a loved one

Just going through a really difficult time in general.

Other (please provide us with some general information about the recipient's situation)

Question Title

* 9. Is there anything that you'd like share about the individual you are nominating, that would give volunteers ideas on how to personalize their cards? Keep in mind that recipients will remain anonymous to volunteers.

Things you might consider including about the person: hobbies, favorite color, favorite show or band, favorite food, etc...

Postmarked with Love Recipient Nomination

Recipient Nomination Form

Question Title

* 1. Your contact information

Question Title

* 2. Tell us a little bit about who you are

Question Title

* 3. Who would you like to nominate?(if nominating a minor, please list minor's first/last name and include guardian's name and contact information if known)

Question Title

* 4. The person you are nominating is... (select multiple if more than one applies)

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* 5. Card recipient age group

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* 6. Do you know the card recipient's preferred gender pronoun?

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* 7. Card recipients primary language?

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* 8. Is the person you are nominating navigating any of the following difficulties?

Question Title

* 3. Who would you like to nominate?
(if nominating a minor, please list minor's first/last name and include guardian's name and contact information if known)

* 4. The person you are nominating is...
(select multiple if more than one applies)