Day in the Park
To apply for our Day in the Park program, please complete the following application. If you have not already completed our online application, we will send you a link to complete it. We require diagnosis verification from your healthcare provider if you have not already provided us with a letter or submitted a completed healthcare form. Submission of an application is not a guarantee for approval. Funds are limited and based on availability.
Sign in to Google to save your progress. Learn more
Parent/ Guardian's Name *
Email Address *
Phone Number *
Address *
Have you completed our online application form? *
Child's Name *
Child's DOB (Any child diagnosed with cancer prior to the child’s 18th birthday is eligible for consideration.) *
MM
/
DD
/
YYYY
Siblings ages 18 and younger (Please list names and age) *
Name of additional parent and/or guardian attending *
Total number of tickets requested (please include child with cancer) *
Race/ Ethnicity (for grant tracking purposes only) *
Is your child in current treatment? (Priority will be given to children in current treatment.) *
Please choose your top 3 favorite local park attractions. We will do our best to fulfill your request when possible. *
Social Worker or Case Manager Email Address or medical provider *
I understand that all applications will be reviewed on a case-by-case basis and a final determination will be made based upon the availability of funds and that the child is currently in treatment for cancer. You will not be discriminated against based on race, religion, color, national origin, sex or political affiliation. *
Required
I authorize Gabriella’s Smile Foundation and its agents and representatives to contact the medical provider in order to verify my child’s cancer diagnosis. I authorize the above named medical provider to release to Gabriella’s Smile Foundation and its agents and representatives any information and medical records deemed necessary by Gabriella’s Smile Foundation to complete its verification of my child’s Cancer diagnosis. I acknowledge that Gabriella’s Smile Foundation will pursue and is entitled to restitution for funds if it is determined that the information submitted on this application is false. *
Required
I grant permission for Gabriella’s Smile Foundation and its representatives to use photographs of my child or myself, our names and my child’s story to inform families, volunteers, the media and the general public about Gabriella’s Smile Foundation and its programs, services and events. Such materials may be used in, among other items, promotional materials, newsletters or on the internet. If permission is granted above, I, for myself and my child, release all claims against Gabriella’s Smile Foundation and its representatives with respect to copyright ownership and publication, including any claim for compensation related to use of these materials. (Photographer may be present to take photos) *
Required
Parent Full Legal Name (Digital Signature) *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of GABRIELLA'S SMILE FOUNDATION. Report Abuse
Google Forms