Bereaved Child Intake Form
For children who have lost a parent or grandparent. Due to the high volume of requests it could be a six month wait 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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Email *
Your Name *
Phone Number *
Your relationship to the child *
City and State you live *
How you heard about us *
Child's Name (First and Last) *
Child's Age and Gender *
Child's Mailing Address - Must include unit number if applicable. We will not be able to track down and replace missing gifts.  *
City *
State *
Zip code *
If there are any other children living at this address who qualify please list name, age, and gender here.
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.  *
How they lost their loved one:
By acknowledging this I am allowing Charlie’s Guys or Project Lightwell 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. 
Please provide details of theme, character, game so we can purchase something they like if they are not selecting the rabbit stuffy. Gifts are under $30.
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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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. *
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