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Please complete this application as fully as you can. Lock Boxes of Love creates personalized boxes for siblings of children with cancer, and complete information, verification, and signed releases are required before approval.

Parent/Guardian or Nominator Full Name

First NameLast Name

Email Address

Phone Number

Area CodePhone Number

Full Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Sibling Receiving the Lock Box Full Name

PrefixFirst NameLast Name

Sibling Age

Gender or Pronouns

Sibling Receiving the Lock Box — Interests & Favorite Things

Please tell us about the sibling who will receive the Lock Box—favorite colors, characters, hobbies, sports, activities, snacks, comfort items, or anything else that will help us personalize their box.

Child with Cancer — Full Name

First NameLast Name

Child with Cancer — Diagnosis

Briefly share the diagnosis and any helpful context.

Relationship Between the Children

Brief Family or Story Context

Please tell us the most important details that help us understand their situation.

Please tell us a little about the sibling receiving the Lock Box and how their sibling’s cancer experience has affected them.

Tell us how this gift would help and what makes it meaningful for them.

Verification from the Child’s Medical Team

Medical verification is required before approval. It must come from a member of the child’s treating hospital, oncology, or medical team and only needs to confirm the child’s full name and that the child has been diagnosed with or is being treated for cancer.

Supporting links such as Facebook, CaringBridge, GoFundMe, or another public page may help us review the application and understand the family’s story, but they do not replace medical-team verification.

Medical Contact Full Name

First NameLast Name

Medical Contact Role or Title

Hospital or Cancer Center

Official Work Email

example@example.com

Work Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Supporting Verification Link(s) — CaringBridge, GoFundMe, Facebook, or Other Public Page

Supplemental links only; do not replace medical verification.

Verification may be provided by an email from an official hospital or clinic email address, or by a signed letter on hospital or clinic letterhead.

I confirm that the required medical verification has been submitted or arranged directly from the child’s medical team.

Liability Waiver / Release

By submitting this application, the signer releases Lock Boxes of Love, its successors, and assignees from any claims, damages, demands, costs, expenses, and liabilities related to participation in or receipt of the Lock Box.

Media Release

By submitting this application, the parent/guardian or authorized nominator grants Lock Boxes of Love permission to photograph, record, reproduce, publish, and share submitted or provided photographs, videos, artwork, written material, the child’s image or voice, and related story content, with or without the child’s first name, for Lock Boxes of Love purposes including its website, Facebook, Instagram, social media, newsletters, fundraising, promotional materials, and other print or digital media. Lock Boxes of Love may edit or crop materials while preserving their intended meaning.

Liability Release Consent

Media Release Consent

Certification / Authorization

First NameLast Name

Electronic Signature

Certification Date

Date

Lock Boxes of Love Sibling Application