Pediatric Holiday Gift Program Request

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Holiday gift requests can be made for youth who are currently on service with a pediatric hospice program in the state of South Carolina. Requests can be made during the months of October - November. and must be made through Amazon.com unless under special circumstances (contact info@hpcfoundation.org if this is the case for you). A member of the patients care team must make this request and it cannot be made by a parent/guardian or relative.

Email *

Your Name (first and last) *

Is the patient currently on service with a pediatric hospice program in the state of South Carolina *

If the patient is not currently on service with a pediatric hospice program in South Carolina this request will not be approved.

Yes

Patient's Name (First and Last) *

Patient's Date of Birth *

Patient's Gender *

Male

Female

Is a parent/guardian of the patient a US Veteran or serve in the military? *

Yes

Patient's Ethnicity *

COUNTY (within South Carolina) Patient Resides In *

Please describe briefly the holiday gift item you are requesting (ie: a game, gift card, toy, clothing, etc.) *

If you are requesting a gift card, what is the amount of the gift card you are requesting (please note the limit on holiday gift requests is $75)

Please provide a web link to the item on Amazon.com (if you have a special circumstance where the item cannot be purchased on Amazon, please contact us at info@hpcfoundation.org). *

If you are requesting more than one item please include the second link here. If only one please type N/a *

IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM

If you are requesting more than two items please include the third link here. If only two please type n/a *

If you are requesting more than three items please include the forth link here. If only three please type n/a *

If you are requesting more than four items please include the fifth link here. If only four please type n/a *

If you are requesting more than five items please include the sixth link here. If only five please type n/a *

Would you like this item be Emailed or Mailed? *

Mailed

Emailed

If you selected the mailing option who's attention should this package be made to? *

Name of person package should be addressed to. MUST be parent or guardian unless it is a special circumstance. If you need the item mailed to you as the caseworker, please provide a detailed explanation on the written form you will sign after completing this request. If item is to be emailed, please type N/A.

STREET ADDRESS where this item should be mailed? *PLEASE verify that this address can receive deliveries from USPS, FedEX, UPS and other major carriers.* *

Indicate the following: ADDRESS (unclude apt number here if applies) If Emailing type N/A

CITY where this item should be mailed? *

If Emailing type N/A

STATE where the item should be mailed *

If Emailing type N/A

ZIP CODE where this item should be mailed. *

If Emailing type N/A

If you selected the mailing option, please also include the parent/guardians phone number (required by several delivery options).

(xxx) xxx-xxxx we will not use this number for our own purposes and it will only be used for the shipping address incase the delivery company has trouble finding the address

If you selected the Email option what email address should this be sent to?

Please double check that there are no typos in the email address provided.

Please indicate the relationship of the person the item is being mailed, to the patient. *

Member of Pediatric Care Team, I will deliver to the patient (requires a detailed explanation on the written form that accompanies this request)

Parent/Guardian

Other:

Please select which of the following (can check more than one) will be a direct result of the Hospice & Palliative Care Foundation providing this resource to your patient. *

Reduce financial barriers for parents/caregivers seeking to provide comfort and joy for a child through requested items and experiences

Allow the child and his or her family to engage in memory making through special activities (i.e. visiting parks, museums, theater performances, etc.)

Promote positive feelings for the child and his or her family through meeting their request for wanted items (i.e. toys, electronics, etc.)

Other:

Required

This is part one of the application process. Part two is to download the accompanying .pdf on the website, complete and sign it, and email it to info@hpcfoundation.org. Please note we cannot accept pictures of the written form from your phone and it must be scanned into a scanner. Contact us at info@hpcfoundation.org if you have any questions or cannot locate the form. Thank you! *

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A copy of your responses will be emailed to the address you provided.

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