Princess Hailey's Hope Foundation: Hugs from Hailey Request Form

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Our Hugs from Hailey program seeks to brighten the days of children diagnosed with cancer. We send personalized care packages to children who are battling DIPG/DMG to encourage them to keep fighting and send treats and toys to clinic to let these little warriors know how special they are. Complete this form to let us know you would like to receive Hugs from Hailey.

Learn more about Princess Hailey's Hope Foundation: https://princesshaileyshope.org/programs

Email *

Patient's Name (First and Last) *

Patient's Age *

Parent/Guardian's Full Name *

Mailing Address *

Please include your complete mailing address including Street Address, Apartment (if applicable), city, state and zip code.

Diagnosis *

DIPG

DMG

Diagnosis Date *

YYYY

Name of Hospital/Treatment Center *

Oncologist Name *

Social Worker's Name and Contact Information *

A general idea of things your child likes (e.g., characters, colors, favorite snacks or stores, etc.). We like to personalize the packages as much as possible. *

Do you have a Facebook support page, Caring Bridge site, Go Fund Me, or Instagram we can follow? If so, please provide site information/handle. If not, please mark "n/a" *

How were you referred to Princess Hailey's Hope Foundation? *

Please let us know how else we can help. We would be happy to get you in touch with parent support networks, other foundations, Facebook groups, etc. Our Facebook and Instagram pages are @princesshaileyshopefoundation. You can also reach us by e-mail at princesshaileyshope@gmail.com.

We love to see and share pictures with your Hugs from Hailey with your permission. They help raise awareness and we are also happy to link your family's Go Fund Me or support sites. You can submit pictures to princesshaileyshope@gmail.com or via FB Messenger at @princesshaileyshopefoundation

By submitting this form, I certify that all information is true to the best of my knowledge. Princess Hailey's Hope Foundation also has permission to contact our social worker to verify my child's diagnosis if deemed necessary. *

I agree

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

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