Christmas to Remember 2023
IThis program is for children or children of parents that with life threatening illnesses that are between the ages of 0-10 and or believe in Santa (certain exceptions may apply).
Name *
Age *
Phone Number *
Email *
Birthday *
MM
/
DD
/
YYYY
Diagnosis *
Address *
Physician Name *
Physician Phone number *
Parents Names *
Address *
Is your child still in treatment,if not date of last treatment or surgery. *
Siblings names ages in household
Have you participated in Christmas assistance programs in the past(including Jamie’s Dream Team) or are you participating in other programs this year, if so which ones? *
Please include a bio with likes and dislikes and send a picture of your child to the email Christmastorememberjdt@gmail.com *
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