Jaiden's Joy Box application
This is the form to apply for jaiden's joy box, a care package made by #teamjaiden! we specialize in packages for kids, teens, and young adults up to the age of 21, however all fighters of all ages will be considered. To be applicable you must meet the following criteria:

1. you must have a medical condition requiring a medical device OR have a diagnosis of cancer or another life-threatening illness
2. you must currently be receiving treatment or frequent medical attention
3. If you are under the age of 14 this application should be submitted by a parent, sibling, or guardian

If you meet all the above criterias we look forward to making you a package! All information given to us is kept private and is only used for your joy box!! Make sure to tag us in your pictures and follow our social media accounts listed below...

instagram: @teamjaiden00
facebook page: Jaiden Rose Buckert- IJM Kansas teen 2017

Email address *
Phone number *
Your answer
Name of recipient *
Your answer
Age *
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DD
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YYYY
Gender *
Do you have any social media pages? (Personal and/or medical) if so list them below *
Your answer
What are your Current Diagnoses? *
Your answer
What hospital(s) are you treated at? *
Your answer
Do you have any medical devices? (port, NG tube, picc, button, wheelchair, crutches etc) *
Your answer
Do you have a service animal? *
do you have any allergies or restrictions? (food/candy, scents, makeup/bath products) *
Your answer
What is you favorite: color, animal, hobby, food/candy, character, tv show/movie, store/brand, activity,etc *
Your answer
Is there anything you would like to see included in your package? (makeup, bath products, arts and crafts, medical mask, etc.)
Your answer
What Clothing size do you wear? *
Your answer
What address would you like your package sent to? *
Your answer
Tell us a little more about your story *
Your answer
Do we have permission to share your story?
Do you have any siblings? If so what are their age(s) and gender(s)
Your answer
Comments and questions:
Your answer
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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