Trach Basket Request
Superman Sam's Survival Kit (S^3 Kit) is a 501(c)(3) nonprofit organization with a mission to give hope to families and caregivers who bring their child home from the hospital with a lifesaving breathing tube (tracheostomy). S^3 Kit does this by giving a basket filled with items to ease their transition home. Fill out the form to give a complimentary basket. After submitting this form, baskets will be shipped or delivered within five business days. Thank you for giving a gift that tells the recipient, "Someone else has been in your shoes." 
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Email *
What is your name?
Is the child a girl or a boy?
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How old is the child? 
Do you know the expected discharge date of the child? If so, when? Ideally, we like to give families/caregivers the basket within a few weeks of the child's discharge date.
What is the address the basket will be sent to? 
If the address is a hospital, what is the name of the hospital? What unit should the basket be sent to?
What is the contact name for the address? 
Do you want the family/caregiver to know you requested the basket?
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Is English the primary language spoken in the home? If not, what is the primary language? 
Anything else you want us to know?
A copy of your responses will be emailed to the address you provided.
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