Small Gift Request
Small gift requests can be made for youth who are currently on service with a pediatric hospice program in the state of South Carolina. A member of the patients care team must make this request and it cannot be made by a parent/guardian or relative.
Email address *
Your Name (first and last) *
Is the patient currently on service with a pediatric hospice program in the state of South Carolina *
If the patient is not currently on service with a pediatric hospice program in South Carolina this request will not be approved.
Patient's Name (First and Last) *
Patient's Date of Birth *
Patient's Gender *
Is a parent/guardian of the patient a US Veteran or serve in the military? *
Patient's Ethnicity *
County Patient Resides In *
Please describe briefly the small gift item you are requesting (ie: a game, gift card, movie tickets etc) *
If you are requesting a gift card, what is the amount of the gift card you are requesting (please note the limit on small gift requests is $100 excluding tax and shipping)
Please provide a web link, where the item can be purchased. *
IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM
If you are requesting more than one item please include the second link here. If only one please type N/a *
IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM
If you are requesting more than two items please include the third link here. If only two please type n/a *
IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM
If you are requesting more than three items please include the forth link here. If only three please type n/a *
IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM
If you are requesting more than four items please include the fifth link here. If only four please type n/a *
IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM
If you are requesting more than five items please include the sixth link here. If only five please type n/a *
IF LINKING TO AMAZON PLEASE SUBMIT THE LINK USING WWW.AMAZONSMILE.COM
Would you like this item be Emailed or Mailed? *
If its a tangible item it will need to be mailed, if it is online tickets, an e-gift card etc. Those can be emailed to save on shipping
If you selected the mailing option who's attention should this package be made to? *
Name of person package should be addressed to. If Emailing type N/A
STREET ADDRESS where this item should be mailed? *PLEASE verify that this address can receive deliveries from USPS, FedEX, UPS and other major carriers.* *
Indicate the following: ADDRESS (unclude apt number here if applies) If Emailing type N/A
CITY where this item be mailed? *
If Emailing type N/A
STATE where the item should be mailed *
If Emailing type N/A
ZIP CODE where this item should be mailed. *
If Emailing type N/A
If you selected the mailing option, please also include the parent/guardians phone number (required by several delivery options).
(xxx) xxx-xxxx we will not use this number for our own purposes and it will only be used for the shipping address incase the delivery company has trouble finding the address
If you selected the Email option what email address should this be sent to?
Please double check that there are no typos in the email address provided.
Please indicate the relationship of the person the item is being mailed, to the patient. If not the parent, you will need to provide a complete explanation on the written form stating why the parent/guardian cannot receive this directly. *
Please select which of the following (can check more than one) will be a direct result of the Hospice & Palliative Care Foundation providing this resource to your patient. *
Required
Note this is a two-step process. Please download from the website, fully complete and get signatures as indicated, and send your written form to info@hpcfoundation.org. Contact this email if you have questions. *
A copy of your responses will be emailed to the address you provided.
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