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. 

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* 1. Your contact information

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

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* 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)

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* 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?

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* 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...

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