Mini Questionnaire
Questions about the child to help customize their mini
What is the child/recipient's name? *PLEASE ONLY REQUEST FOR YOURSELF OR YOUR CHILD, we do not take friend requests
What is the child/recipient's age? *only ages 2-17 please as we have limited supplies
Choose 4 favorite stuffed animals
Teddy Bear
Dinosaur
Bunny
Dog
Tiger
Surprise
Mini mini (6”-8”)
Other
Choose 4 favorite colors
Red
Blue
Orange
Yellow
Purple
Black
Green
Pink
White
Colorful Animal
Classic Animal
Other
What medical conditions and/or devices do they have? *There are some conditions we may not be able to reflect; please let us know if surgical feeding tubes are danglers or buttons. Please include the color of AFOs or other medical items. If you do not have a device please put treatments options that are done. Photos are helpful, you can email them to medicalminisjoy@gmail.com
Why would you or your child benefit from a Medical Mini? (Aubrey loves reading everyone’s stories)
Email address so we can contact you regarding the mini
*
Address you want the mini mailed to (only shipping within the USA at this time, PLEASE READ BELOW REGARDING SHIPPING)
*
If we run out of funds would you be willing to pay the $8-$10 for shipping?
Yes
Maybe
No, wait for more donations
How did you hear about Medical Minis?
Instragram
Facebook
Friend
News
Other
Policy & Disclaimer: Medical Minis may contain small pieces that can be choking hazards. Many medical supplies used in the minis can be removed/taken out so that children can see and learn about them. No needles nor sharp objects are used in any minis. Do you agree to release Medical Minis, Inc, supply donors, and all volunteers from any possible injury that may occur once the mini is mailed?
*
Yes
No
Submit
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