Nominate a Family

The criteria for nominating a child in need are as follows:

Child has to be under age 18
Child has to be currently in treatment for a high risk cancer, cancer that is likely to recur or spread with unfavorable prognosis (per their physician)
The family requires assistance, i.e., financial or services
The applicant needs to reside in the USA.

33%

Parent/Legal Guardian's Name*
First Last
Their Email*
Their Phone Number*
Their Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Name of Child*
First Last
Child's Date of Birth*
Date Format: MM slash DD slash YYYY
Age of Child*
School Child Attends & Grade

Diagnosis*
Is Child Considered High Risk (Per Physician)?*
Date Diagnosed*
Date Format: MM slash DD slash YYYY
Is Child Currently in Treatment?*
*If No, is treatment no longer an option (i.e. Hospice)?
Name of Hospital Child is Currently Treated at?
Tell is this Child's Story:*
What are the Family's Immediate Needs During this Time in their Child's Treatment? (Ex: Financial - rent/mortgage assistance, utility bills, gas cards, etc. or Services- boarding for animals, lawn mowed, etc.)*
Is there anything this fighter would want to put a smile on his/her face? (Ex: Art & Crafts, Games, Electronics, ect.)
By Typing your Name Below you are Certifying that the Provided Information is Correct to the Best of your Knowledge.*

Laney's Legacy of Hope