Home | Ride Janie Ride

The mission of the Ride Janie Ride Foundation is to provide direct financial assistance to Chicagoland individuals facing financial hardship resulting from ongoing medical treatment for various types of cancer.

Ride Janie Ride Nomination Form

Please provide as much detail as you can about your nominee by answering the questions below.

Your First and Last Name *

Your Email *

Subject *

Your Phone Number *

Best Time to Call *

Nominee First & Last Name *

Nominee Phone Number (Optional)

Nominee Email Address (Optional)

Nominee Address (Include City, State, and Zip Code) *

Nominee Approximate Age *

Date of Diagnosis (if known)

Nominee Marital Status *

Nominee Spouse/Partner First Name (If Applicable) (Optional)

Does the nominee have dependent children? *

Yes

Is the nominee employed? *

Yes

Is the spouse/partner employed (if applicable)?

Yes

Does the nominee have health insurance? *

Yes

Does the nominee have blood cancer? *

Yes

Your answer will have no bearing on the nominee being fully and fairly considered as a potential recipient.

Is the nominee currently receiving treatment? *

Yes

Is the nominee a legal U.S. resident? *

Yes

Does the nominee know you are nominating them? *

Yes

Has the nominee had previous fundraisers on their behalf? *

Yes

If you answered "yes" to the previous question, what was the date of their last applicable event?

May we contact the nominee? *

Yes

How do you know the nominee? *

Tell us why you believe this person should be considered by the Ride Janie Ride Foundation. *

Submit