Your name
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First Name
Last Name
Your child's name
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First Name
Last Name
Current mailing address if different from the initial application
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Would you be willing for people to send you items such as cards, toys, etc? All of these items would be mailed to us, and we would forward them to you so you would not have to share your address online.
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Where in the treatment schedule is your child?
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Do you need any supplies or adaptive style clothing for your child’s access/port/feeding tubes?
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Is treatment primarily inpatient or outpatient?
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Are there any handicaps, physical limitations, or developmental delays that we need to know about or can help with?
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Is your child able to speak or use any type of communication?
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In relation to your answer on the previous question, does your child need additional resources to further their development? If so, please specify if speech, sign language, or both would be more beneficial to your child. We have some books, flashcards, games, etc. that we can send.
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Does your child have any sensory issues and if so, what kinds?
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What specific current needs not mentioned above does your child have? Please don’t be hesitant to mention anything.
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What size of clothing is your child wearing? Is there any specific type/style/color of clothing that they prefer?
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What is your child’s favorite interests? Color? Animal? Music? Books?
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What types of crafts does your child enjoy doing?
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As the parent, what do you need for yourself? Books/Bible/Quran/Stress reliever/Coffee/Coloring books/etc?
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What Is the one item you wish existed that does not that could help with treatments (for you as a parent and for your child)?
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Please give us your story. Start from the beginning prior to diagnosis. What if any hurdles were there in reaching a diagnosis? How has treatment been going? How has all this affected your life as well as your family as a whole? What has been the hardest obstacle so far? What can you share with other people that have never gone through this so that they can better understand your journey? Has there been any positive experiences and changes along the way? Answer to the extent you feel most comfortable. There can be some good, some bad, and some downright ugly times during treatment which we want raise awareness about so please don’t feel like you must hold back or “edit” your responses.
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