Golden Gala Sponsorship by borellidesigns | Sep 25, 2019 Golden Gala Sponsorship 1Your Info2Parent's Info3Child's Diagnosis Your Name* First Last Relationship to Child* Your Email* Your Phone Number*How did you find out about Laney's Legacy of Hope grant program?* Parent/Legal Guardian's Name* First Last Their Email* Their Phone Number*Their Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Name of Child* First Last Age of Child*Child's Date of Birth* MM slash DD slash YYYY Diagnosis* Is Child Considered High Risk (Per Physician)?*YesNoDate Diagnosed* MM slash DD slash YYYY Is Child Currently in Treatment?*YesNo*If No, is treatment no longer an option (i.e. Hospice)?YesNoName of Hospital Child is Currently Treated at?* Tell is this Child's Story:*Has this child/family ever received assistance from Laney's Legacy of Hope in the past?*NoYesUnsureWhat are the Family's Immediate Needs During this Time in their Child's Treatment? (Ex: Financial - rent/mortgage assistance, utility bills, gas cards, etc. or Services- boarding for animals, lawn mowed, etc.)*By Typing your Name Below you are Certifying that the Provided Information is Correct to the Best of your Knowledge.* Δ
