Recipient Nomination Form
Information About You
First Name:     Home Phone:     Best Time To Call:    
Last Name:     Cell Phone *:     E-Mail Address:    
Information About Your Nominee
First Name:     Address:     Zip:    
Last Name:     City:     Cell Phone *:    
Home Phone:     State:     E-Mail Address *:    
How do you know the nominee? Does nominee know you are nominating them? Nominee approximate age  
Nominee marital status Is nominee employed? Does nominee have dependant children?  
If married spouse's first name Is spouse employed? Does nominee have a blood cancer? **  
Is nominee still working? Does nominee have health insurance? Is nominee currently receiving treatment?  
Date of original diagnosis May we contact the nominee? Is nominee a legal US resident?  
Has the nominee had previous fundraisers on their behalf?  
If so, what was the date of the last event? **  
Please Copy And Paste The Code In The Box  
Tell us why you believe this person should be considered by the Ride Janie Ride Foundation as a potential recipient of financial assistance due to their medical condition.
characters left
* Optional
** Your answer will have no bearing on the nominee being fully and fairly considered as a potential recipient

Privacy Statement
Ride Janie Ride Foundation will not sell, lease or rent your personal information. The information collected will be used to identify potential recipients only. The Ride Janie Ride Website does not capture IP addresses nor does it place tracking cookies on a client computer.

Ride Janie Ride Foundation takes seriously the trust you place in us. To prevent unauthorized access or disclosure, to maintain data accuracy, and to ensure the appropriate use of the information, Ride Janie Ride Foundation utilizes appropriate physical, technical and administrative procedures to safeguard the information we collect.

Map Ride Janie Ride Foundation is an IRS 501(c)(3), State Tax Exempt compliant organization Site Map