#FriendofFRAXA Submission

If you would like to nominate someone as a #FriendofFRAXA, simply complete the form below. We welcome all who have been touched by Fragile X, including friends, grandparents, siblings, professionals and companions alike. We’ll then review the submission and include it on our site and feature it on our social media accounts. The goal of #FriendofFRAXA is to put a face to Fragile X for those who may not know someone directly.

#FriendofFRAXA Image*
.jpg or .png, max 32MB. We may crop the photo to apply our overlay.
Accepted file types: jpg, png, jpeg, Max. file size: 500 MB.
#FriendofFRAXA First Name*
First name of the #FriendofFRAXA featured in the image.
#FriendofFRAXA Age
If you feel comfortable, please provide an age.
#FriendofFRAXA Hometown*
City State / Province / Region Country
Highlight
Choose to highlight Interests and Challenges or an Accomplishment for this #FriendofFRAXA nomination.
- Interests/Challenges
- Accomplishment
#FriendofFRAXA Interest
Please provide a couple of interest your #FriendofFRAXA has. Can be anything from playing on their iPad, watching trains, playing in the rain, etc.
#FriendofFRAXA Challenges
Please provide a couple of challenges your #FriendofFRAXA has. Can be anything from hearing the happy birthday song, riding in the car, loud noises, crowds, etc.
#FriendofFRAXA Accomplishment
Please provide a brief accomplishment that your #FriendofFRAXA nomination has done. Can be outlining dedication to helping someone with Fragile X, assistance in fundraising, research accomplishment, etc.
What is something you wish everyone knew about your nominee?
Your Name*
First Last
Your Email*
In case we need to contact you.
Mailing List
- Add impact to your inbox. Join our email list and invest in the difference FRAXA makes.
Media Consent - Printed materials
- I give permission for FRAXA to use this picture in printed materials in addition to social media and website.
Media Consent - Third parties
- I give permission for FRAXA to share my picture with third parties (educators, researchers, or journalists) for publication.
Name
This field is for validation purposes and should be left unchanged.