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Holiday Families 2020
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* Indicates required question
Email
*
Your email
Child's Full Name
*
Your answer
Please check off that the recipient (child) meets all of the following criteria.
*
Child ages 0-17 (as of 12/31/2020)
Currently residing in the United States
Diagnosed with a life-altering illness
Required
Child's Age (as of 12/31/2020)
*
Your answer
Child's Birthday (including year)
*
MM
/
DD
/
YYYY
Full name of the person filling out the form
*
Your answer
Your relationship to the child
*
Parent
Other family member
Friend
Self
Other:
Name of parents / guardians (all)
*
Your answer
Names and ages of siblings
*
Your answer
Child's Diagnosis
*
Your answer
Prognosis
*
Your answer
Date of diagnosis / onset of illness (approximate is ok)
*
MM
/
DD
/
YYYY
If cancer or similar, is the child...
*
Currently in treatment
In remission
A survivor
Not applicable
Other:
What hospital(s) is the child treated at?
Your answer
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