Parent/Guardian's Name
*
First Name
Last Name
Email
*
Where is your child receiving treatment?
Hospital
Upcoming Appointments
*
We will try to coordinate delivery with an appointment day. If you are unsure, please put N/A
Child receiving treatment (Name & Age)
Child receiving treatment's gender
Male
Female
Any specific basic needs?
Clothing or Shoes (Please list sizes), School Items, Basic Necessities
What are specific items they would like?
*
Interest, Characters, Sports, etc. (Feel free to put links)
Child #2 Name & Age
Child #2 Gender
Male
Female
Any specific basic needs?
Clothing or Shoes (Please list sizes), School Items, Basic Necessities
What are specific items they would like?
Interest, Characters, Sports, etc (Feel free to put links)
Child #3 Name & Age
Child #3 Gender
Male
Female
Any specific basic needs?
Clothing or Shoes (Please list sizes), School Items, Basic Necessities
What are specific items they would like?
Interest, Characters, Sports, etc. (Feel free to put links)
Child #4 Name & Age
Child #4 Gender
Male
Female
Any specific basic needs?
Clothing or Shoes (Please list sizes), School Items, Basic Necessities
Any specific items they would like?
Interest, Characters, Sports, etc. (Feel free to put links)
Child #5 Name & Age
Child #5 Gender
Male
Female
Any specific basic needs?
Clothing or Shoes (Please list sizes), School Items, Basic Necessities
What are specific items they would like?
Interest, Characters, Sports, etc.(Feel free to put links)
Child #6 Name & Age
Child #6 Gender
Male
Female
Any specific basic needs?
Clothing or Shoes (Please list sizes), School Items, Basic Necessities
What are specific items they would like?
Interest, Characters, Sports, etc (Feel free to put links)
What are Mom's/Caregiver's favorite things or stores?
What are Dad's/Caregiver's favorite things or stores?
Anything else you want us to know?
Let us know if you need to come back and finish the form later.
Are you in need of Christmas decorations?
Christmas Tree, ornaments, lights, stockings (please list quantity), etc.
Do you have preferences on colors?
(We will do our best to accommodate your preferences)
Do we have your consent to share a little about your family's journey thus far?
This has NO effect on your eligibility to participate in the program. We value your family's privacy preferences.
Thank you so much for completing this form, this helps us know what your children need and like. We will be in touch to coordinate delivery of your items. Christmas decor start being delivered the week of November 24th. Gift deliveries will start the week of December 8th.
If you have any questions, pleas email info@haleyrascofoundation.org
