Angel Tree Family Application
Enter your family details and each child’s date of birth for the VVHAF United Biker Ride & Santa Toy Drive (Etowah County, AL).
Parent or Guardian Email
*
example@example.com
Parent or Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Does your family reside in Etowah County?
*
Yes
No
Patient’s Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Super Sibling Date of Birth One
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Super Sibling Date of Birth Two
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Super Sibling Date of Birth Three
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Super Sibling Date of Birth Four
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Super Sibling Date of Birth Five
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How did you hear about us
Please Select
Facebook
Voice and Value Event
Social Worker
Hospital or Clinic
Other
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Brave Patient Name
Note:
Please keep each gift under fifty dollars.
Wish List Number One
Wish List Number Two
Wish List Number Three
Boy, Girl, or Other
Brave Patient Favorite Toys
Brave Patient Favorite Color
Brave Patient Favorite Hobbies
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Brothers and sisters carry a lot during treatment, too. Tell us what would make their super sibling(s) smile.
Super Sibling 1 Gender
Please Select
Girl
Both
Other
Super Sibling 2 Gender
Please Select
Girl
Both
Other
Super Sibling 3 Gender
Please Select
Girl
Both
Other
Super Sibling 4 Gender
Please Select
Girl
Both
Other
Super Sibling 5 Gender
Please Select
Girl
Both
Other
Super Sibling(s) Favorite Toys
Super Sibling(s) Favorite Color
Super Sibling(s) Favorite Hobbies
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Proof of Diagnosis
*
Upload File
Drag and drop files here
Choose a file
Upload a clear copy of the diagnosis proof.
Cancel
of
Signature
*
HIPAA Compliance Statement:
This form may collect protected health information (PHI). By submitting this form, you understand that the information you provide will be handled in accordance with applicable privacy and security requirements.
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