A Healing Grace

Healing families with grace and faithfulness through God.

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About A Healing Grace
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Help Us
Family Application
Support A Family
- SelahGrace
- Elaina
More

Home
Donate
About A Healing Grace
In Loving Memory
Help Us
Family Application
Support A Family
- SelahGrace
- Elaina
More

A Healing Grace Family Application

(hit send at the bottom of each section)

Child's Information

Child's Full Name*

Child's DOB*

Diagnosis and date of diagnosis*

Hospital/ Hospitals*

Treating Physician*

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Submitted

Consent/ Release- Social Media, Print, Publicity, Printed & Electronic.

Consent/ Release*

I AGREE and hereby grant full permission to A Healing Grace to use either myself or my child/children’s name(s) and photograph in any publication or advertising materials (printed or electronic), and social media. This consent serves to waive all rights of privacy or compensation which I may have in connection with the use of my photograph and/or my child’s photograph or name. IF YOU AGREE, be sure to follow our social media sites to see your child’s story featured!I DO NOT AGREE to have mine or my child/children’s name(s) photograph used for public viewing.

Does your child have any pages online dedicated to their cause? (Examples Facebook page, Caring Bridge, GoFundMe). Please list the URL's below.*

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Submitted

Financial Assistance

Parent 1- Employment*

Parent 2- Employment

Please briefly describe any financial issues the family is facing.

Have you been contacted by Children's Cancer Partners Of The Carolinas?*

YesNo

Do we have your permission to forward your application to Children's Cancer Partners Of The Carolinas? (If you answered no above)

YesNo

Make A Wish- A child with a critical illness who has reached the age of 2½ and is younger than 18 at the time of referral is potentially eligible for a wish. After a child is referred, Make-A-Wish® will work with the treating physician to determine the child's eligibility for a wish, i.e suffering from a progressive, degenerative or malignant condition currently placing the child's life in jeopardy. Have you applied for a Wish?

YesNo

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Submitted

How Else Can We Help Your Family?

Please let us know how we can help below.

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Submitted

Parent Or Guardian Information

Parent Or Guardian Full Name*

Email Address*

Mailing Address*

Phone Number*

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Submitted

Siblings

Full Name and DOB

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Submitted

Connections

Would you like us to connect you with another local family that has a child with a similar diagnosis?*

YesNo

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Submitted

I verify that all of the information I have submitted on this application page is true.

I verify that all of the information I have submitted on this application page is true. Please Print Your Electronic Signature*

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Submitted