Care Package Request Form
This form will be used to determine how the Isla Cares Foundation can best support and encourage your child and family. Please fill out the form completely and allow 3-5 business days for a reply.
Personal Information
Please fill this information out completely.
Child's Name
*
First Name
Last Name
Parent/Guardian Names
First & Last Name
First & Last Name
Contact E-mail
*
example@example.com
Phone Number
Gender
*
Male
Female
Child's Birthday
*
-
Month
-
Day
Year
Date
Child's Ethnicity
American Indian or Alaskan Native
Asian
Black or African American
Hispanic or Latino
White
Native Hawaiian or other Pacific Islander
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Medical Information
This information is only for our records and will not be shared in any capacity on any of our platforms.
Medical Document Upload
*
Browse Files
Drag and drop files here
Choose a file
This can be any medical form that includes the child's name and diagnosis. Please do not upload forms that contain sensitive information, such as social security numbers.
Cancel
of
Briefly describe the child's current treatment status
*
Tell us about your child!
We will use this information to personalize a care package for your child. Please share details about how we can bring joy to your child as well as how we can help your family.
Favorite Color
Interests & Hobbies (Reading, sports, crafts, cars, building, etc.)
*
Favorite Animal
Favorite Books, Shows, Movies, and/or Characters
Family Information
This information will help us determine how we can best support and encourage your family as a whole.
Siblings' Genders & Ages
What does your family enjoy doing together?
Where does your family shop for groceries?
WalMart
Target
Price Chopper
HyVee
Aldi
Other
Where does your family like to eat together?
Where do you typically go to purchase gas?
Is there anything else you would like to share with us about your child and/or your family?
What is your preferred method of contact?
Phone Call
Email
Text
How did you hear about Isla Cares?
Facebook
Instagram
Event
Friend or Family
Google
Other
Submit
Should be Empty: