Share your Golden Hero’s Story

Parent/Legal Guardian Name

First Name

Last Name

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

Child's Birthdate

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

Have you submitted a photo of your child to tay@withlovecharity.org? (if not, please do so with subject: [your child's name]

Yes

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.