Comfycozy's for Chemo Application

Child's name *
Child's name
9/19/2019 ]
This will be shared with our supporters on social media
color, characters, toys... etc
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9/19/2019 ]
Child's doctor
Child life specialist *
Child life specialist
Parent's name *
Parent's name
Parent's address *
Parent's address
(if applicable)
Acknowledgement *
By checking the box below I acknowledge that I have a child age 0-18 with cancer or a life-threatening medical condition (i.e., progressive, degenerative, malignant or any such condition that may jeopardize the child’s life) and I/we agree to give Amanda Hope Rainbow Angels permission to contact my child’s physician/s for confirmation of the qualifying criteria of cancer or a life-threatening medical condition.
Release agreement *
By checking the box below, I hereby authorize the release of information to Amanda Hope Rainbow Angels.
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