Family Application

We know the beast that is pediatric cancer and how it drains not only the warrior battling it daily, but also the entire family. Is there something special your family would like to do together to help take a “break”? Let us help create that memory and bring your family some much deserved JOY!

If you are a Mississippi family currently battling pediatric cancer, please fill out the form below and let us know what we can do for you.

*Applicants must be Mississippi residents and currently in treatment and/or hospice.

*Patient must be between the ages of 0-18 years old.

*If you do not fit the above guidelines, please let us know and we can help provide information for other possible resources!

Name

First Name

Last Name

Relation to child

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Child's Name

First Name

Last Name

Child's Birthday

YYYY

Diagnosis

Hospital

Social Worker's Name and Email

N/A if nominating a family

Names & Ages of Other Children in Family

Share child's story, including diagnosis and journey thus far

How can we best help your child create more memories?

Occasionally, we like to share featured stories. Please check the box if you give us permission us to post about your child on our social media platforms.

*We will only use first names when sharing the family's story. *This is NOT a requirement in order to apply.

I give permission to share.

Family Application

Help us make memories for pediatric cancer families.