Nomination Form - Ride Janie Ride Foundation

Nomination Form

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

Name*

Email*

Your First & Last Name*

Your Phone Number*

Your Email Address*

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 Original 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