Bare Bottom Bear Request

Bare Bottom Bear Request

A Bare Bottom Bear is a classic teddy bear dressed in a hospital gown and mailed to bring comfort, joy, and a smile during surgery or another challenging treatment. You may request a bear for yourself or submit a request on someone else’s behalf.
Recipient Information
Recipient Full Name

First NameLast Name
Recipient Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Recipient Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Requestor Information
Requestor's Name

First NameLast Name
Relationship to Patient

Other
If other relationship to patient, please specify
Requestor's Email Address
example@example.com
Requestor's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Reason for Request
Reason for Request

Other
Surgery/ Procedure Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Request - Other
Program Referral
How did you hear about the Bare Bottom Bear Program?

Other
If Other, how did you hear about the program?
Additional Information (Optional)
If I am submitting this request on someone else’s behalf, I confirm that I have their permission to share their name, mailing address, and the information provided above.
Should be Empty: