Cali Kids Assistance Request Form
Please fill out the request form and we will deliver a hospital survival kit to you and your child in a San Diego hospital. If you have a greater financial or other support need, please explain at bottom of form and we will do our best to assist you or to find additional resources.
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Email *
Child's Name (First and Last) *
Parent(s)/Guardian's name. (First and Last name who is staying in hospital with child) *
Parent's cel phone number. (Used only to text to coordinate hospital delivery.) *
Child's age *
Child's favorite's (color, interests/hobbies, shows, characters, etc...) *
Siblings: name, age, interests/hobbies, favorites (colors, characters, etc.) *
Name of hospital child is admitted to in San Diego, CA. *
Date of admittance *
MM
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DD
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Estimated length of stay *
Child's diagnosis *
Greatest Need(s) (choose up to 5) *
Required
Name and relationship requester *
Are you experiencing a loss of income due to your child's hospitalization? *
Have you or child's other parent/guardian lost your job or had to quit your job due to your child's medical condition? *
Link to fundraisers, social media or website for the child's medical journey (GoFundMe, Facebook, Caring Bridge, ETC...) *
We post photos of the care package and a little about the child receiving a gift. We only post the first name and and a brief blurb about the child's diagnosis. We do not post other personal information or in depth details about the child's medical journey unless we are hosting a fundraiser for the family and the parent gives permission. If requested, we will only use the child's first initial and leave out the diagnosis. *
Required
We love receiving photos of the child/family with their care package! We would love to see photos of your child(ren) with their gifts! We will not share the photos unless you give us permission. It makes a big impact to our donors when we post photos of these photos on our social media and website. We only post photos with parent's permission. *
How did you hear about us *
Financial or other assistance needed *
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