Bereaved Family Application

Bereaved Family Application
Date of Application*

MonthDayYear
Name of Parent Applying*

First NameLast Name
Applicant's Email Address*
Applicant's Partner/Child's Parent (you may skip if single parenting)

First NameLast Name
Partner's Relationship to the Child that died:
Partner's Email (optional, encouraged)
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Applicant's Phone Number*

Area CodePhone Number
Partner's Phone Number (if applicable)

Area CodePhone Number
Applicant's Gender Preference

FemaleMaleNon-binary
Partner's Gender Preference (if applicable)

FemaleMaleNon-binaryNot applicable
Family's Race/Ethnicity (choose all that apply)

American Indian/Alaskan NativeAsian/Pacific IslanderBlack or African AmericanHispanicWhite/CaucasianI rather not say
Name of Child that has Passed (If you have lost more than one child, please list as a sibling and let us know more about them in the additional details at the bottom of this page.)*

First NameLast Name
Child's Gender Preference

FemaleMaleNon-binary
Child's Birthdate*

MonthDayYear
Child's Date of Diagnosis*

MonthDayYear
Child's Age at Diagnosis*
Primary Diagnosis*
Date of Child's Passing*

MonthDayYear
Child's Age at Death*
Sibling 1 Name
Sibling 1 Gender

NAFemaleMaleNon-binary
Sibling 1 Birthday

MonthDayYear
Sibling 2 Name
Sibling 2 Gender

NAFemaleMaleNon-binary
Sibling 2 Birthday

MonthDayYear
Sibling 3 Name
Sibling 3 Gender

NAFemaleMaleNon-binary
Sibling 3 Birthday

MonthDayYear
If you have additional children, a second child with cancer, or a second child that died, please add their information here:
Tell us something special about your family or your child that died (optional):
How Did You Hear About Us?*

Facebook/InstagramHospital Liason (Social Worker/Resource Room)Another nonprofit (list under other please)Found website on GoogleOther/Friend (please tell us who)
Name of friend that referred you to Rett's Roost:
Should be Empty: