Brave Warrior's Name
*
First Name
Last Name
Brave Warrior's Nickname
Brave Warrior's Date of Birth
*
Date of Birth
MM
DD
YYYY
Brave Warrior's Gender
*
This is helpful as we shop for each family member
Type of cancer
*
Date of Diagnosis
*
MM
DD
YYYY
Current status of cancer
*
Parent 1 Name
*
First Name
Last Name
Parent 1 Phone Number
*
(###)
###
####
Parent 1 Email
*
Parent 1 Relation to the Brave Warrior
*
Mom
Dad
Step-Mom
Step-Dad
Guardian
Parent 2 Name
First Name
Last Name
Parent 2 Phone Number
(###)
###
####
Parent 2 Email
Parent 2 Relationship to the Brave Warrior
Mom
Dad
Step-Mom
Step-Dad
Guardian
Parent 3 Name
First Name
Last Name
Parent 3 Phone Number
(###)
###
####
Parent 3 Email
Parent 3 Relationship to your Brave Warrior
Mom
Dad
Step-Mom
Step-Dad
Guardian
NONE
Parent 4 Name
First Name
Last Name
Parent 4 Phone Number
(###)
###
####
Parent 4 Email
Parent 4 relationship to your Brave Warrior
Mom
Dad
Step-Mom
Step-Dad
Guardian
NONE
Additional Family Info
Please include any additional information about your family that you would like us to know.
Number of family members living at home
*
1
2
3
4
5
6
7
8
9
10
10+
Number of Siblings
*
1
2
3
4
5
6
7
8
9
10
10+
No Siblings
Sibling 1 First and Last Name
First Name
Last Name
Gender
This is helpful as we shop for each family member
Date of Birth
MM
DD
YYYY
Sibling 2 First and Last Name
First Name
Last Name
Gender
This is helpful as we shop for each family member
Date of Birth
MM
DD
YYYY
Sibling 3 First and Last Name
First Name
Last Name
Gender
This is helpful as we shop for each family member
Date of Birth
MM
DD
YYYY
Sibling 4 First and Last Name
First Name
Last Name
Gender
This is helpful as we shop for each family member
Date of Birth
MM
DD
YYYY
Please include additional siblings and their info here
First and Last Name, Gender, Date of Birth, Ethnicity/Race and Favorite Things
Address (Where the Brave Box should arrive)
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Billing Address (Where your bills arrive)
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
County
*
Is this a PO BOX?
SELECT A CHOICE
YES
NO
Is there any additional information that will be helpful to know regarding the mailing address?
I am applying for a Brave Box on behalf of...
*
Which Brave Boxes are you most interested in receiving? Check all that apply
*
We cannot guarantee that you will receive the box you select. We will do our best to provide your preferred Brave Box.
Are there any specific items that would be helpful?
Expense Box Survey
*
Which of these gift cards would your family be interested in receiving?
We cannot guarantee receipt of these gift cards, but will certainly consider your preferences.
Brave Warrior's Favorite Colors?
Brave Warrior's Favorite Characters, Movies or TV shows?
Brave Warrior's Favorite Games, Toys or Activities
Brave Warrior's Favorite Stores
Brave Warrior's Favorite Restaurants
Brave Warrior's Favorite Drinks
Brave Warrior's Favorite Foods
Brave Warrior's Favorite Snacks
Brave Warrior's Favorite Music or Artists
Brave Warrior's Favorite Books or Author
Brave Warrior's Favorite Hobbies
Our family loves to go to these places!
Please select any of these places that your family enjoys going to.
If your family could go anywhere in the US, where would your family could go anywhere in the US, where would you choose to go? Why is that place special to you?
Is there anything you would like to add for the Activities that the family loves?
Please share any additional family favorites here!
Parent/Guardian Dreams
If there were no limitations, what do you dream of receiving as a gift?
Is there anything we should know about any of your family members? (Example: dislikes, sensory issues, things your child cannot have, developmental age)
How did you hear about Brave like Ellie?
*
Brave like Ellie Board Member
Brave like Ellie Volunteer
Brave like Ellie event
Social Media
Website
Friend
Relative
Other
Are you willing to give feedback throughout the program?
*
I agree that Brave Like Ellie may use our likeness/image in promotional materials.
*
Images will be used for us to share our impact.
Are there additional resources that your family could use at this time?
Are there any other ways we can support the Parents/Guardians?
Do you have a page where people follow the child’s journey?
*
Yes
No
Not yet, but we may create one
Would you like us to share it with our audience for support?
Yes
No
You may share it with the Brave like Ellie team, but not publicly
Provide links to any pages you would like us to share.
