The Light Collective: MATCHBOX Registration
Welcome!

Our monthly MATCHBOX program provides everything you need to spark a lighthearted day of family fun, and a chance to connect with other families on the same journey.

WHO WE SERVE:
::  Our MATCHBOX program is intended for families who have a child receiving active treatment or within one year of finishing active treatment for a cancer diagnosis, usually involving chemotherapy and/or radiation.  

::  For now, we are limited to serving families in the Pacific Northwest.

::  Families living in the Seattle area will have boxes delivered to your door by TLC volunteers.  Families who live farther away will have boxes shipped to your home.

::  NOTE:  Signing up for one event is not a long-term commitment.  We will contact you to sign up for future MATCHBOX events, if you are interested.  


HOW THIS WORKS:
::  Complete this form, and we'll add your family to our list.

::  We will be in touch before the event with a bit more information and a few announcements.

::  We will deliver a day of FUN for your family to enjoy from the safety and comfort of home (which might be your house, your apartment, your room at the Ronald McDonald House, or your hospital room).

::  This monthly experience will include:
     -  Dinner! (Each family will receive a gift card for GrubHub / UberEats / DoorDash so you can order dinner from your favorite spot, delivered to your door. We can also reimburse your expenses for a take-out dinner if a delivery service doesn't work for you.)
     -  A big box filled with fun and silly activities, games, and crafts for your whole family to enjoy together.
     -  A few interactive experiences on Zoom, including crafts, family games, and a safe and expertly-facilitated time of connection just for parents and caregivers.

MORE STUFF YOU SHOULD KNOW:
::  This experience is offered FREE for families. We are delighted to include all members of your household if you have grandparents, cousins, etc. who live with you full time.

::  Our team takes every precaution in the packaging and delivery of your boxes to make sure your family is safe.

::  If you are able, we hope you'll plan to enjoy the meal and the box contents AND ALSO participate in the interactive Zoom times. We believe there is deep joy and lots of hope to be found when families can connect with one another. Come as you are--we're not fancy or fussy.

::  What if only some of my family wants to participate? What if we're going back home to Montana in two months? What if I can't participate on Zoom, but I still want the box and the meal? Good questions! Please don't hesitate to reach out and let's chat:
JJ Kissinger
Executive Director, The Light Collective
jjk@lightcollectivepnw.org
206-799-8988

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THE BASICS:
Guardian #1 FIRST AND LAST NAME *
Guardian #1 Preferred Pronouns
Guardian #1 TYPE (i.e. parent, grandparent, step-parent, adult sibling, foster parent, etc.) *
Parent/Guardian #2 FIRST AND LAST NAME
Guardian #2 Preferred Pronouns
Guardian #2 TYPE (i.e. parent, grandparent, step-parent, adult sibling, foster parent, etc.)
Child #1 First and Last Name
Child #1 Date of Birth
MM
/
DD
/
YYYY
Child # 1 Preferred Pronouns
Child #1 Interests, likes, dislikes
Child #2 First and Last Name
Child #2 Date of Birth
MM
/
DD
/
YYYY
Child #2 Preferred Pronouns
Child #2 Interests, likes, dislikes
Child #3 First and Last Name
Child #3 Date of Birth
MM
/
DD
/
YYYY
Child #3 Preferred Pronouns
Child #3 Interests, likes, dislikes
Child #4 First and Last Name
Child #4 Date of Birth
MM
/
DD
/
YYYY
Child #4 Preferred Pronouns
Child #4 Interests, likes, dislikes
Additional Children: Please include same info asked above.
Caregiver #1 EMAIL *
Caregiver #2 EMAIL
Best Phone Number *
Alternate Phone Number
Permanent Address: STREET *
Permanent Address: CITY *
Permanent Address: STATE *
Permanent Address: ZIP *
Current Address of Residence, if different from permanent address.  (i.e. Where should we deliver your Box of Fun?  This might be your RMH Room #, Seattle Children's Room #, or TBD if you're not sure where you will be.)
INFO ABOUT THE PATIENT
Name of Patient *
Diagnosis *
Date of Diagnosis *
MM
/
DD
/
YYYY
On active treatment? *
If NOT on active treatment, what was the date when you finished active treatment?
MM
/
DD
/
YYYY
Primary Medical Facility *
Name of provider managing treatment *
Name of social worker *
Do we have your permission to contact your health care team to verify treatment dates and consult about providing this program for your family? *
JUST A FEW MORE QUESTIONS
How did you hear about this opportunity?
Any allergies in your family? (You do NOT need to list allergies to medications or seasonal allergies--we're looking for any allergies that might be triggered by items we send in the boxes, like foods, latex, etc.)
Does your family have access to a device that will allow you to participate in a Zoom call?
Clear selection
We invite families to share photos of their Matchbox experience on a private photo sharing site called Cluster. If you share photos, we may use them on our social media sites, or for promotional purposes. Do you grant The Light Collective permission to use photos or videos you have shared for any lawful purpose including publication, promotion, advertising, or historical archive, and release The Light Collective and its legal representatives from liability for any violation or claims relating to said images or video? *
Does your family feel comfortable with the basic navigation of Zoom?
Clear selection
We hope to facilitate virtual gatherings on Zoom that feel safe and welcoming for all families, volunteers, and staff. When we gather on Zoom, we prohibit profanity, hateful and discriminatory speech, aggressive / threatening / violent language, nudity, inappropriate sexual language, acts of violence or aggression, substance abuse, any illegal activity, and any behaviors that violate Zoom's Community Standards, as outlined here: https://explore.zoom.us/en/community-standards/. Do all members of your family agree to respect and uphold these standards when we gather on Zoom? *
Has your family received support from other nonprofit organizations?  If yes, which ones?
Anything else we should know about your family?  (Helpful info includes: Any physical, mental, or sensory conditions that might hamper anyone's ability to play active and/or on-screen games? Any special talents your kids might want to share? Anything else that would help us serve your family well?)
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