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SCDF Back to School Backpack Giveaway
for school aged children (Grades TK-12) living with sickle cell disease
Please note the locations and days for pick up below:
Los Angeles / MLK SCD Outpatient Clinic (Tuesdays & Thursdays)
Harbor UCLA Medical Center (Tuesdays & Thursdays)
Long Beach / Miller Childrens Medical (3rd Thursday of the month)
Ontario / SCDF Office (Mondays & Wednesdays)
Orange / Center for Inherited Blood Disorders (Tuesdays & Thursdays)
Davis / UC Davis Medical Center (Wednesdays & Fridays)
Name of person completing form:
*
First Name
Last Name
Relationship to child with SCD
*
Please Select
Parent/Guardian of child with SCD
Other Relative
SCDF Staff
Name of child with sickle cell disease
*
First Name
Last Name
DOB of child with SCD
*
-
Month
-
Day
Year
Date
Age & Grade of child with SCD
*
Ex: Age 12, 6th Grade
Is the child a Current SCDF Client?
*
Please Select
Yes
No
Unsure
Proof of diagnosis and California residency will be required for any applicant who is not a client of SCDF.
Total number of school aged children living in the home
*
Grades TK-12
Total number of school aged children in the home with sickle cell disease
*
Grades TK-12
Your signature below indicates that you consent to being a client of the Sickle Cell Disease Foundation (SCDF).
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Your Phone Number:
*
Texts Accepted?:
*
Please Select
Yes
No
Email:
*
Confirmation Email
example@example.com
Appointments Schedule
You may ONLY select one location. Selection of multiple locations is not permitted.
Los Angeles/MLK Appointments (9:00 am - 3:30 pm)
Harbor UCLA Appointments (9:00 am-2:30 pm)
Long Beach Millers Memorial Appointments (1:00 - 4:00 pm)
Ontario SCDF Office Appointments (9:00 am-3:30 pm)
Orange CIBD Appointments (10:00 am-4:00 pm)
Application will be submitted when you hit the red submit button below. The specifi pick up details will be sent to me by email. I understand that if I cannot make it to my appointment, I will contact the Foundation to cancel.
*
I understand
Submit
For office use only:
SCDF Follow up
Comments/Notes:
Should be Empty: