Referral form for Be Bold Be You Foundation

The object of the Be Bold Be You Foundation (BBBYF) is for the public benefit: to relieve the needs & promote the mental health and wellbeing of those affected by cancer and/or pre-cancerous cells who reside in the Midlands and South Yorkshire by providing:

a free, professional, photoshoot experience using the genres of modelling or boudoir photography
a professionally printed tryptic folio of the user’s three favourite images
a digital gallery of up to ten of their favourite images for personal use.

BBBYF, a registered charitable incorporated organisation (CIO in England & Wales, charity number 1211365) will not authorise an application for purposes which are not charitable or inline with its own objects as outlined in its constitution.

Please only apply if you meet one or more of the following criteria:

The person being applied for has been affected by cancer
The person being applied for has been affected by pre-cancerous cells
The person being applied for lives & resides in the Midlands or South Yorkshire
The person being applied for has not received a Be Bold Be You Foundation experience within the last 3 years.

Please note:

By sending in this application form you confirm that the information you have provided is correct and to the absolute best of your knowledge.

Name of the referee:

First Name

Last Name

Job Title

Please note: Referrals from health care professionals will be given priority

Name of establishment and postal address, including postcode:

Email of referee

This will be used to ask for additional details, if needed as well as let you know of the outcome one of this application

Relationship with the individual being nominated

ie. Patient, family member, friend, work colleague, pupil, etc.

First name of the individual being nominated

At this stage, please only include their first name.

Is the person being nominated under the age of 18? If so, please provide their date of birth.

We'll need to contact the child's parent/legal guardian to act as a chaperone throughout their time with BBBYF

Postcode & county of the person being nominated

Please note we can only accept referrals for those living & residing in the Midlands and South Yorkshire.

Reason for referral

EG. Has an immediate family member affected by cancer/precancerous cells; needs a confidence boost; the work of BBBYF would have a positive impact on the individuals mind, body and/or spirit; has never had a photoshoot before

The date in which the cancer / pre-cancerous cells were found/diagnosed:

A month & year is acceptable if the specific date is unknown at this stage

BBBYF aims to make all decisions, on applications, within 60 days of receipt. With this in mind please state below if you feel a quicker decision is needed and the reason(s) for this:

eg. Due to have an operation; on palliative care plan; is at school

Please confirm the following:

- The user is confident that they will be able to physically participate in the shoot which include standing for long periods of time & changes of clothing (up to 3 times) within 60 minutes - The user is confident that they feel of sound mind to participate in a shoot and is able to look at photographs of themselves without potential detriment to their own mental wellbeing (BBBYF will not change/remove and/or enhance any physical bodily features in post production editing and will not agree to any requests by the individual to do so, if asked) - The user is able to participate in a 4 hour experience including sitting, standing, posing and being of sound mind to choose their final images to receive in print and/or digitally - The user is able to confidently speak and understand English as a language, as interpreters are not available

I confirm to the above four points

I am unable to confirm the above four points

Please let us know which experience the user is wanting to have

A modelling photoshoot

A boudoir photoshoot (strictly for those over the age of 21 yrs and above)

The user has not decided yet

I don't know