Family Application

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A Healing Grace Family Application

Child's Full Name*

Child's DOB*

Diagnosis and date of diagnosis*

Hospital/ Hospitals*

Treating Physician*

Email Address*

Phone*

Parent or Legal Guardian Full Name*

Mailing Address*

Siblings Full Names & D.O.B

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

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.

URL's /Links For Your Child's Cancer Journey

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

Financial Assistance

Please briefly describe any financial issues the family is facing.

Parent 1- Employment

Parent 2 - Employment

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

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

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

YesNo

How Else Can We Help Your Family? Please let us know how we can help below.

I verify that all of the information I have submitted on this app 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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