Gift Box Request form

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Please fill out if you would like a gift box sent to someone battling cancer

Anonymous or name of person giving gift box *

anonymous

name of person giving gift box--fill in name below

If you wish your name to be known to the recipient, please write first and last name below

Name and address of the person receiving the gift box

Please provide the full name and address (including zip code)

Describe the person receiving the gift box *

Person is recently diagnosed and not yet in treatment--encouragement box

Person has started conventional treatment (chemotherapy/radiation/immunotherapy etc)

Person is undergoing surgery

Person is done with treatment--recently finished chemotherapy or radiation--celebration box

Person is done with treatment and needs rejuvenation box

Person is ready for exercise and would like sneakers, a fit bit, and a mini-trampoline

Other--please note any other themes, reasons for the box or items you want included

If you chose other, please explain below

Please check off items you think the recipient would like in the box *

tea

inspirational mug

inspirational desk calendar

Movie/books/tv series--list below any particular show/movie/book of interest

pets, animals--list below a particular animal lover (cats, dogs, snakes, etc)

spiritual--particular religion or type of gift--rosaries, prayers, psalms--list below

certain scents-lavendar, cinnamon, apple and spice etc. list below

particular hobbies, interests "soccer mom, loves cows or garden gnomes--any unique or special interests)

t-shirt --what size

slippers--what size

sports--items for a particular team (NBA, NFL, Soccer, Hockey etc. --list which team in box below)

Other:

Required

For any items that required specific answers (sizes, colors, names of teams etc. please list below)

Any additional ideas, items to include in the box please list below

Please leave your contact information below in case we have questions (email and cell phone *this information is only to be used for gift box donation questions) *

If you would like to make a donation towards our gift box campaign, please click on this link

https://www.paypal.com/donate/?hosted_button_id=4LK84AXHWVUR6l

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