Refer a NICU/PICU Sibling
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Email address *
Your Name *
Please list details here:
-Name of child (hospital patient)
-Illness
-Name of hospital
 *
Point of Contact at Hospital/First and Last name *
Please list the SIBLINGS (name, gender, and age) *
Relationship to the child/ren you are referring *
How you heard about us *
City and State in which you live *
Physical Address to send children's gift *
City *
State *
Zip code *
Phone Number *
Select One *
Please describe games or themes to purchase and if there are multiple children with various interests, please list them here (e.g. Child 1: Star Wars Legos, Child 2: Minecraft video game for Nintendo Switch, etc.) *
Anonymous Gift *
By acknowledging this I am allowing Charlie’s Guys to send a gift to the child/ren referred and assuming responsibility of the gift once it has been delivered. *
Social Media page link to verify identity *
The following information we need in order to apply for grant funding. Please check one box that identify the children.
Annual Household Income - for grant demographic purposes only, does not impact your qualifications for our services
Clear selection
Have you received a NICU/PICU sibling gift in the past? *
I hereby declare that the information provided is true and correct. I also understand that any willful dishonesty may render for refusal of this application. *
Required
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