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Bereaved Child Intake Form
For children who have lost a loved one that is not a sibling. Due to the high volume of requests it could be a couple months before we send out your gift. Once we purchase a gift we will send you the shipping confirmation to expect it in the mail.
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* Required
Email
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Your email
Your Name
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Your answer
Your relationship to the child
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Your answer
City and State you live
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Your answer
How you heard about us
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Your answer
Child's Name (First and Last)
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Your answer
Child's Age and Gender
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Your answer
Child's Mailing Address - Must include unit number if applicable. We will not track down and replace missing gifts.
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Your answer
City
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Your answer
State
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Your answer
Zip code
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Your answer
If there are any other children living at this address who qualify please list name, age, and gender here.
Your answer
First and Last name, Date, and Relationship of lost loved one, website, gofundme, obituary or other way to verify loss. Gifts are only sent to families that have been verified.
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Your answer
How they lost their loved one:
Your answer
By acknowledging this I am allowing Charlie’s Guys to send a gift to the child/ren referred and assuming responsibility for the gift once it has been delivered.
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Yes
No
Please select from the drop down the gift category preference.
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Choose
Art/craft
Toy
Video game
Electronic
Sports
Please provide details of theme, character, game so we can purchase something they like. Gifts are under $50.
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Your answer
We can only send a gift to a child once. Please confirm this child has not already received a gift from us.
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Child has not received a gift previously.
Are you interested in learning more about Charlie's Clubhouse - a way for bereaved kids to connect?
Yes
No
Clear selection
Are you interested in learning more about our grief therapy stipend program?
Yes
No
Clear selection
The following information we need in order to apply for grant funding. Please check one box that identify the children.
African American
Asian
Biracial
Caucasian
Indian Asian
Native American or Pacific Islander
Latino
Multiracial
Native American or Eskimo
Annual Household Income - for grant demographic purposes only, does not impact your qualifications for our services
Under $75,000
$75,000-$100,000
$100,000-$150,000
$150,000-$200,000
Above $200,000
Clear selection
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.
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Yes
No
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