Barad's Blanket Request

Barad's Blanket Request

Donated by the Barad family, Barad’s Blankets brings comfort to Pals worldwide. Receive a cozy, plush blanket by mail as you head into or home from surgery or other challenging treatment, along with a reminder that no matter what you are going through, you are not alone.
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
Reason for Request - Other
Surgery/ Procedure Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Program Referral
How did you hear about Barad's Blanket 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: