BrittiCares International CHILD REFERRAL FORM

CHILD REFERRAL FORM

This is form is for “Imagine Me” Bed Room Makeovers, and “Pick A Parties” only. At this time, all other requests must be made by the request of a hospital social worker. BrittiCares determines a child’s medical eligibility with the assistance of the treating physician. To receive one of our Dream Services, a child must be diagnosed with Cancer, Leukemia, or other Life threatening blood diseases.

If you are the parents or legal guardian of a child who has reached the age of 4 years old, and is under the age of 19 who may be eligible to receive one of our dream services (“Imagine Me” bedroom makeover, or “Pick A Party”), please fill out the form below and mail or fax it to BrittiCares International c/o of Care Coordinator P.O. Box 43504 Los Angeles, CA 90043 or Fax 323-292-8527. Parents, medical professionals or social workers may refer a child. Currently, we are only accepting referrals of California residence. Certain restrictions apply.

I AM REFERRING A CHILD FOR THE FOLLOWING DREAM SERVICE

“Imagine Me” Bed Room Makeover Pick A Party

First name:

Last name:

Relationship to child:

Address:

City:

State:

Zip Code:

Country:

Email:

Telephone:

Fax:

I would like to be added to your e-mail list Yes No

COMMENTS

Please contact me as soon as possible regarding this matter.

If you need additional information, please e-mail us at info@BrittiCares.org. or contact our office.