The Kindness Project Nomination Form
To be eligible for a Kindness Project, the patient/survivor must live in the Metro St Louis area.
Your Name
*
First Name
Last Name
Your Email
*
example@example.com
Your Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Cell Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Who do you want to nominate (It could be yourself)?
*
First Name
Last Name
Email of the person you want to Nominate
*
example@example.com
Cell Phone Number of the person you want to Nominate
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address of the person you want to Nominate
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is your relationship with the Nominee?
*
What type and stage of cancer does your friend or loved one have?
*
Tell us your/their cancer story? :
*
Why should you/your person be supported by 3 Little Birds 4 Life?
*
How are you/they managing your/their cancer?
*
Would you be interested in being the Team Leader for your nominee (basically the contact point between us and the nominee, and you would help us design certain aspects of their Kindness Project)?:
*
Yes
No
If Not, Who would you recommend that we ask to be the Team Leader?:
How did you hear about 3 Little Birds 4 Life?:
*
What Kindness Project Category Below Would You Think You/Your Nominee Would Like? You may pick more than one (but that doesn't mean we will have the capability to do everything, it just helps us/you with ideas and things you/they may like).
*
Everyday Confetti (yard work, errands, cleaning, laundry, groceries, meals)
Celebrations (clean scans, head shaving parties, ringing the bell)
Family Activities (movie nights, family outings, dinner out or dinner in)
Other (**We are open to all suggestions within reason and our capabilities**)
If you put "Other"... what is your suggestion?
Please upload a photo of Yourself/Nominee
*
Browse Files
Drag and drop files here
Choose a file
Cancel
of
I agree to allowing 3 Little Birds 4 Life to use my/family media and any media from my Kindness Project to be used for any marketing or any use to further the mission of the organization
*
Yes
No
Save
Submit
Should be Empty: