Child's Mailing Address - Must include unit number if applicable. We will not track down and replace missing gifts. *
Your answer
City *
Your answer
State *
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Zip code *
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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. *
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. *
Please select from the drop down the gift category preference. *
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. *
Your answer
We can only send a gift to a child once. Please confirm this child has not already received a gift from us. *
Are you interested in learning more about Charlie's Clubhouse - a way for bereaved kids to connect?
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Are you interested in learning more about our grief therapy stipend program?
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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
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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. *