Winter Celebrations Program Application
How it works: Families or individuals can apply by providing a wish list of gifts or experiences they would like for the winter holidays. Med City Foundation will then provide this information to individuals or groups in the community to meet these needs. The supporters are only provided with first initial, age, sex, and wish-list of the requests. Gifts are distributed by Med City Foundation. Those participating can request gifts or an experience if there is something they would like to do in the community for the holiday season.

How to qualify: Individuals must have an active diagnosis of a blood cancer (leukemia, lymphoma, or myeloma) and be staying either permanently or temporarily within Rochester. For families to qualify, an immediate family member must be actively receiving treatment for a blood cancer and have the appropriate referral as stated above.

Gifts can be picked up on Saturday December 21st in Rochester at the Med City Foundation office. Alternate date and time for pick up may be available if needed.

Complete the information below about you and/or your family. Please provide gift ideas for ALL family members (this includes adults) and be as specific as possible. If you are requesting clothing, provide sizes.

Your name *
Name of person completing form
Your answer
Email *
Your answer
Phone number *
Your answer
How many individuals (including yourself) are in the family? *
Your answer
Name, age, and diagnosis of family member battling a blood cancer
Your answer
Name of medical provider to confirm diagnosis (this can be a MD/DO, NP/PA, nurse, and/or social worker)
Your answer
Anything you would like to share about yourself or your family with donors (this is completely optional but include history of your journey with cancer, things your family enjoys doing, etc)
Your answer
Next
Never submit passwords through Google Forms.
This form was created inside of Med City Foundation. Report Abuse