Request For Services

Thank you for your interest in applying for the CLF4Kids free programs. Our mission is to support and lift the spirits of children because no one should fight cancer alone. Our programs are created to inspire confidence, spark joy, and empower children, all while nurturing a love for learning. We invite you to review the eligibility requirements below before submitting your application. To be considered for participation, applicants must meet the following criteria: 1. Must be under 21 years of age at the time of application. 2. Must have received treatment within the continental United States. 3. Must disclose whether they have previously received services from CLF4Kids. Thank you for allowing us the opportunity to support your journey and be part of your child's continued strength and resilience.

Parent / Legal Guardian

Parent or Legal Guardian Full Name *

Relationship to Child *

Parent or Legal Guardian Email Address *

Phone Number *

Please enter a valid phone number.

Shipping Address

Shipping Address (for delivery of the gift if selected) *

Child Information

Child's Full Name *

Child's Date of Birth *

Child's Age (must be under 21) *

Date of Diagnosis (MM-DD-YYYY) *

Type of Cancer Diagnosis *

Is your child currently in treatment? *

Yes No

Care Team

Social Worker or Child Life Specialist Name *

Phone Number *

Email Address *

Name of hospital, City, State *

Additional Questions

Tell us about your child and what we can do to lift their spirits? *

Has your child ever received services from us before? *

Yes No

If selected, do you agree to provide a short video (1–2 minutes) of the gift reveal and your child enjoying it along with 2–3 photos of your child with their gift? *

Yes, I agree No, I do not agree

Media Consent: I understand and agree that photos and video may be shared by CLF4Kids on social media, their website, and in fundraising materials.

* I confirm that I am the parent or legal guardian of the child named above and that all information provided is accurate to the best of my knowledge. I understand that submission does not guarantee selection and that gifts are awarded based on available funding.

Signature

Signature *

Sign above. Your signature is saved on submit.

Date *

Upload

Photo of child (2MB size limit)*

Verification Image *

You will be notified by email within two weeks of submission. Be sure to check your email for confirmation. You are welcome to email us with any questions at contact@clf4kids.org.