Child's Name *

First Name

Last Name

Child's Birthday *

We will send your child a birthday card!

MM

DD

YYYY

Race/ethnicity that best describes the child *

American Indian / Alaska Native

Asian

Black / African American

White - Non-Hispanic

White - Hispanic

Hispanic / Latino

Native Hawaiian / Pacific Islander

Multi-Racial

Middle Eastern / North African

Other

Prefer not to say

Child's Diagnosis Date *

This shows if you meet the requirement of your child being diagnosed before the age of 18 years old to receive a free Comfycozy's for Chemo adaptive apparel item

MM

DD

YYYY

Child's Child Life Specialist or Social Worker *

This is our best point of contact at the hospital

First Name

Last Name

Child's Child Life Specialist or Social Worker's Phone

(###)

###

####

Parent's Name *

You will be our main contact for any questions/updates regarding your child's application

First Name

Last Name

Parent's Phone *

(###)

###

####

Mailing Address *

This is where we will send the Comfycozy's for Chemo adaptive apparel item, backpack, and mindfulness kit

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Acknowledgment *

By checking this box, I acknowledge that I have a child with cancer or a life-threatening medical condition (i.e., progressive, degenerative, malignant or any such condition that may jeopardize the child’s life) that was diagnosed before the age of 18 years old. I/we agree to give Amanda Hope Rainbow Angels permission to contact my child’s hospital/medical staff for confirmation of the qualifying criteria of cancer or a life-threatening medical condition.

Release of Information *

By checking this box, I authorize the release of information to Amanda Hope Rainbow Angels

SMS Opt-In

By checking the box, I agree by electronic signature to be contacted about Amanda Hope Rainbow Angels by SMS text at my residential or cellular number, dialed manually or by autodialer (consent to be contacted is not a condition to receive a Comfycozy’s for Chemo adaptive apparel item or other support services) and to be contacted via email. I consent to be contacted even if my phone number or email address appears on an Amanda Hope Rainbow Angels Do Not Call / Do Not Email List, a State or National Do Not Call Registry, or any other Do Not Contact List.