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Legacy Art Request
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* Indicates required question
Child's Name
*
Your answer
Age
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Parent/Guardian
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Address
*
Your answer
Child Life Specialist Information
Child Life Name, Email & Phone number
*
Your answer
Hospital
*
Nicklaus Children's Hospital
Holtz Children's Hospital
Miami Cancer Institute (Baptist)
Alex's Place (UHealth)
Joe DiMaggio
Appointment Date Request
*
MM
/
DD
/
YYYY
Floor & Room #
*
Your answer
Legacy Art choice ( Please choose 1 )
*
Photography
3D Hand Molds
Hand Prints
Patient Eligibility
*
I have completed and submitted a "Patient Membership Application".
My child is currently in palliative care or undergoing an amputation surgery.
My child is 21 years or younger.
I understand that Jar of heARTS does it's best to fulfill requests but assistance is not guaranteed.
Required
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