Share your Golden Hero’s Story Parent/Legal Guardian Name * First Name Last Name Email * I would like to schedule a Golden Hero Box * Yes No, I just want to share my child's story. Best way to contact you: * Mailing Address Address 1 Address 2 City State/Province Zip/Postal Code Country Golden Hero’s Name * Child's shirt size Youth X-Small Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Child's Birthdate MM DD YYYY Are they currently receiving treatments in the following locations? * Jacksonville, FL, or surrounding area Nashville, TN, or surrounding area No, they are receiving treatment somewhere else Please include the Hospital/clinic they are receiving treatment at and the contact information of your child-life specialist there. (Required for verification) * Describe your Hero’s journey with pediatric cancer (Diagnosis, Treatment, etc.) Please be as detailed as possible.: * What changed the most about your child's life during/after diagnosis? * His/Her favorite hobbies, sports teams, pastimes, etc. Please be as detailed as possible. * Does your Hero have any special needs or allergies we need to be aware of? (For example, epilepsy) *Please note, WithLove never sends food of any kind, but some items may be exposed to certain allergens within our box-building environment. We want to be mindful of them as we curate your child’s care package. Does your Hero have a Super Sibling? If so, please state their first name(s), age(s), and a few of their favorite things How did you hear about WithLove? * Is there a prayer page or social media tag we can follow? By clicking submit you agree that all the information provided is true, giving us permission to contact you for future events and are allowing us to share your child's story through our distribution channels as it relates to childhood cancer awareness and interaction with WithLove. * ** Please give us 2 - 5 business days to respond to your submission. "Golden Hero Boxes" are mailed out the last Saturday of the month. We hold the rights to approve or deny any submission. Only upon approval, will your child qualify to be mailed a Care Package. I Agree. Thank you for sharing your child’s brave story. Please allow 2-5 business days for follow up and let your child life specialist know we will be reaching out. We can’t wait to celebrate your Golden Hero!WithLove,Tay Scheibe