Request for services

Request For Services

💛Thank you for your interest in applying for the CLF4Kids free programs. Our mission is to support and lift the spirits of children because no one should fight cancer alone. Our programs are created to inspire confidence, spark joy, and empower children, all while nurturing a love for learning. We invite you to review the eligibility requirements below before submitting your application. To be considered for participation, applicants must meet the following criteria: 1. Must be under 21 years of age at the time of application. 2. Must have received treatment within the continental United States. 3. Must disclose whether they have previously received services from CLF4Kids. Thank you for allowing us the opportunity to support your journey and be part of your child’s continued strength and resilience.
Parent or Legal Guardian Full Name*

First NameLast Name
Relationship to Child*
Parent or Legal Guardian Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Shipping Address (for delivery of the gift if selected)*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child's Full Name*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Child's Age (must be under 21)*
Date of Diagnosis (MM-DD-YYYY)*

MonthDayYear
Date
Type of Cancer Diagnosis*
Is your child currently in treatment?*

YesNo
Social Worker or Child Life Specialist Name *
Email Address and Phone Number *
Name of hospital, City, State*
Tell us about your child and what we can do to lift their spirits?
Has your child ever received services from us before?
If selected, do you agree to provide a short video 1–2 minutes of the gift reveal and your child enjoying it along with 2–3 photos of your child with their gift?*

Yes, I agreeNo, I do not agree
Signature*

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Date

MonthDayYear
Photo of child

Cancelof
You will be notified by email within two weeks of submission. Besure to check your email for confirmation. You are welcome to email us with any questions at contact@clf4kids.org
Please verify that you are human*
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Request For Services