What is your name?
Who are you?
I am a member of the family needing assistance
I am related to the family needing assistance (ex: grandparent, cousin, aunt/uncle)
I am a friend of the family needing assistance
Other:
Enter a phone number/email address where we can contact you
Is the child currently battling cancer?
Yes
No
Other:
Please link a CaringBridge/Facebook account for the child's cancer journey if there is one. We would love to follow along and support you!
What is the age and gender of the child battling cancer? (We provide assistance to pediatric cancer patients ages 18 and under)
What city would you like us to deliver the gifts to? (We mainly provide assistance to families in the Fargo-Moorhead area, but we have provided assistance to families throughout ND and MN. Let us know where you live/receive treatment and we will see if we can accommodate!)
What toys/gifts would the child battling cancer appreciate? (ex: puzzles, toy cars, blankets, gift cards for older children, etc.)
If the child battling cancer has siblings, please list the age and gender of each child below. Please also list toys/gifts that each sibling would appreciate (ex: puzzles, toy cars, blankets, gift cards for older children, etc.)
What would help your family most right now? (ex: gift cards for food, toys to entertain the child during treatment, gift cards for gas, etc.)
Is there anything else you want us to know? Once you have filled out this form please send an email (foreverzachary9@gmail.com) or text (701-306-3917) to let us know you have completed the form! We do not get notifications that someone has completed the survey but check for submissions multiple times per week.