Jaiden's Joy Box application
This is the form to apply for jaiden's joy box, a care package program 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. Siblings of warriors may receive a package as well, simply put the sibling's name, age, and things they like in the comments section below.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 or terminal 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 #joystory 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 *
Name of recipient *
Your answer
Age *
Your answer
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 or a service animal? (port, NG tube, picc, button, wheelchair, crutches etc) *
Your answer
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
What address would you like your package sent to? *
Your answer
Comments and questions:
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms