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Hug of Hope Care Packages
Sending a hug of hope from a far!
21
Questions
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1
Name
Requestor Information
First Name
Last Name
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2
Email
Requestor Email
example@example.com
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3
Phone Number
Requestor Phone Number
Area Code
Phone Number
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4
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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5
Should we address the package to you or your child(ren)?
Me
My child(ren)
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6
Financial Information
Your household income section is optional. However, It will help us with grant information to help more kids and families affected by ALS.
Please Select
less than $20,000
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$69,999
$70,000-$79,999
$80,000-$89,999
$90,000-$99,999
More than $100,000
Please Select
Please Select
less than $20,000
$20,000-$29,999
$30,000-$39,999
$40,000-$49,999
$50,000-$59,999
$60,000-$69,999
$70,000-$79,999
$80,000-$89,999
$90,000-$99,999
More than $100,000
Household Annual Income
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7
Who has ALS in your family and what is their relationship to the Hug of Hope recipient(s)?
*
This field is required.
Father
Mother
Grandfather
Grandmother
Other
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8
Person with ALS' Name
*
This field is required.
First and Last Name
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9
Is this person currently battling ALS?
*
This field is required.
YES
NO
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10
pALS Info
*
This field is required.
If yes, how are they doing?
if no, when did they pass away?
Please feel free to share any additional details about your pALS or family ALS journey.
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11
Recipient Information #1
*
This field is required.
Please provide the information of the child receiving the care package.
First and Last Name
Current Age
Birthday
Woman
Man
Non-binary
Let me type...
I prefer not to say
Woman
Man
Non-binary
Let me type...
I prefer not to say
Which most accurately describe (s) the recipient?
Please Select
Youth (S)
Youth (L)
Adult (S)
Adult (M)
Adult (L)
Adult (XL)
Other
Please Select
Please Select
Youth (S)
Youth (L)
Adult (S)
Adult (M)
Adult (L)
Adult (XL)
Other
Shirt size
Which most accurately describe (s) the recipient?
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12
Books
Our resources and books are pre-selected and divided by the age groups below.
Age 9 and under
Age 9-12
Age 13-16
Age 17-25
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13
Is an additional care package needed?
YES
NO
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14
Recipient Information #2
Please provide the information of the child receiving the care package.
First and Last Name
Current Age
Birthday
Please Select
Woman
Man
Non-binary
Let me type...
I prefer not to say
Adult (XL)
Other
Please Select
Please Select
Woman
Man
Non-binary
Let me type...
I prefer not to say
Adult (XL)
Other
Which most accurately describe (s) the recipient?
Please Select
Youth (S)
Youth (L)
Adult (S)
Adult (M)
Adult (L)
Adult (XL)
Other
Please Select
Please Select
Youth (S)
Youth (L)
Adult (S)
Adult (M)
Adult (L)
Adult (XL)
Other
Shirt size
Which most accurately describe (s) the recipient?
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15
Books
Our resources and books age pre selected and divided by the age groups below.
Age 9 and under
Age 9-12
Age 13-16
Age 17-25
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Enter
16
Is an additional care package needed?
YES
NO
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17
Recipient Information #3
Please provide the information of the child receiving the care package.
First and Last Name
Current Age
Birthday
Please Select
Woman
Man
Non-binary
Let me type...
I prefer not to say
Please Select
Please Select
Woman
Man
Non-binary
Let me type...
I prefer not to say
Which most accurately describe (s) the recipient?
Please Select
Youth (S)
Youth (L)
Adult (S)
Adult (M)
Adult (L)
Adult (XL)
Other
Please Select
Please Select
Youth (S)
Youth (L)
Adult (S)
Adult (M)
Adult (L)
Adult (XL)
Other
Shirt size
Which most accurately describe (s) the recipient?
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Next
Submit
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18
Books
Our resources and books age pre selected and divided by the age groups below.
Age 9 and under
Age 9-12
Age 13-16
Age 17-25
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Next
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Enter
19
How did you hear about Hope Loves Company?
Please Select
HLC Website/Google
Social Media
Friends/Family
ALS Organization
Donor or Sponsor
Other
Please Select
Please Select
HLC Website/Google
Social Media
Friends/Family
ALS Organization
Donor or Sponsor
Other
If you heard of Hope Loves Company from an ALS Organization, which one?
If you heard of Hope Loves Company from a friend or family member, please share their name:
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20
Have you or your child ever participated in an HLC camp, Hangout or event?
In the last 3 years.
Please Select
Yes
No
Please Select
Please Select
Yes
No
Yes or No
Please Select
Camp HLC- in person
Camp HLC-virtual
Monthly Hangouts
Parent Meetups
Fundraising Event
Please Select
Please Select
Camp HLC- in person
Camp HLC-virtual
Monthly Hangouts
Parent Meetups
Fundraising Event
If yes, which program or event
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21
Would you like someone from the HLC team to contac to you to share more information about our programs and services?
YES
NO
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