Sign Up - Little Hearts of Hope

Child's Name*

First Last

Child's age*

Child's Gender*

Male
Female

Emotional Inquiry

Is this child experiencing any of the following emotions since the cancer diagnosis in your family? Please rate each emotion on a scale of 1 to 5, with 1 being very little to none and 5 being regularly.

Jealousy*

embarrassment*

fear/anxiety*

disappointment*

abandonment*

sadness*

anger*

loneliness*

guilt*

Are there more children you would like to sign up? (same address)*

Yes
No

How many additional children?*

one
two
three

Child's Name (#2)*

First Last

Child's age (#2)*

Child's Gender (#2)*

Male
Female

Emotional Inquiry Child #2

Is this child experiencing any of the following emotions since the cancer diagnosis in your family? Please rate each emotion on a scale of 1 to 5, with 1 being very little to none and 5 being regularly.

Jealousy*

embarrassment*

fear/anxiety*

disappointment*

abandonment*

sadness*

anger*

loneliness*

guilt*

Child's Name (#3)*

First Last

Child's age (#3)*

Child's Gender (#3)*

Male
Female

Emotional Inquiry Child #3

Is this child experiencing any of the following emotions since the cancer diagnosis in your family? Please rate each emotion on a scale of 1 to 5, with 1 being very little to none and 5 being regularly.

Jealousy*

embarrassment*

fear/anxiety*

disappointment*

abandonment*

sadness*

anger*

loneliness*

guilt*

Child's Name (#4)*

First Last

Child's age (#4)*

Child's Gender (#4)*

Male
Female

Emotional Inquiry Child #4

Is this child experiencing any of the following emotions since the cancer diagnosis in your family? Please rate each emotion on a scale of 1 to 5, with 1 being very little to none and 5 being regularly.

Jealousy*

embarrassment*

fear/anxiety*

disappointment*

abandonment*

sadness*

anger*

loneliness*

guilt*

Delivery & Diagnosis Information

The following information lets us know where to send the Hope Package as well as details that help us know how we can be of further help.

Are you the child's parent?*

Yes
No

Would you be interested in sponsoring the child's Hope Package for $35/month?*

Yes
No

Please describe your relationship with the child*

Your Name*

First Last

Your Email*

Parent's Name*

First Last

Parent's Email*

Parent's Phone Number*

Address (We are unable to deliver to PO Boxes)*

Street Address City State ZIP Code

County*

Which family member has cancer?*

Type of cancer?*

Date of diagnosis?*

Current status of cancer*

currently in treatment
remission
hospice

Are there other resources the family needs other than the monthly Hope Package?*

Yes
No

Please describe*

How did you hear about Little Hearts of Hope?*

Are you willing to give feedback throughout the program?*

Yes
No

I agree that Little Hearts of Hope may use our likeness/image in promotional materials*

Yes
No

The following questions are optional.

Please note, these answers are kept confidential and are used only in the grant writing process.

What is your household income?

Less than $20,000
$20,000 to $34,999
$35,000 to $49,999
$50,000 to $74,999
$75,000 to $99,999
$100,000 to $149,999
$150,000 to $199,999
$200,000 or more
Choose not to respond

Please specify your ethnicity

White
Hispanic or Latino
Black or African American
Native American or American Indian
Asian / Pacific Islander
Choose not to respond