Please use this form to refer a child to our organization. The information submitted will be used to determine if the child qualifies for our services. The child must be three years or younger currently undergoing cancer treatment. The person filling out this form must also be a parent/legal guardian, treating physician, or child life specialist. Submission of this form gives us the right to verify any of the information. We will respond to all applications in a timely manner. If there are any other circumstances or questions about or beyond this form, please email or call us. All fields marked with an asterisk (*) are required.