Referral

Bear Hugs Submission - Self Referral

Individuals must meet the following criteria to be eligible for a Bear Hug. Bear Necessities will confirm patient information and diagnosis with the hospital team provided prior to accepting the application. If you are a hospital team member, please use the hospital referral link or contact [email protected] for more information.
Patient is between the ages of 0 and 19
- Yes
Patient is being treated for pediatric cancer
- Yes
Patient is a resident of Illinois and/or is being treated at a hospital located in Illinois
- Yes
I am the Parent/Guardian of the Patient; or I am the Patient and 18+ years old
- Yes

Patient First Name*
Patient Last Name*
Patient Nickname, if any
Date of Birth*
MM slash DD slash YYYY
Home Address
Address*
Street Address City State / Province / Region ZIP / Postal Code Country
County*
Name of Hospital Where Receiving Treatment*
Other Hospital ID
Gender*
Race*
Other Race
Name of school patient attends
Patient Email (if applicable or 18+)
Patient Phone (if applicable or 18+)
Patient Website
Guardian Information
No. Parents/Guardians Living with Child*
Parent 1 First Name*
Parent 1 Last Name*
Parent 1 Phone*
Parent 1 Email*
- No email or Not Available
Parent 1 Employer
Parent 2 First Name*
Parent 2 Last Name*
Parent 2 Phone*
Parent 2 Email
Parent 2 Employer
Who does the patient live with?
Total number of individuals in the household*
Sibling Names, Gender and Ages
Example: John M 12; Sarah F 9; Lillie F 3mos
Language(s) spoken at home (include all)*
Approximate Household Income*
(This information is used for data collection; financial information is not a qualifier to receive support from Bear Necessities.)
Hospital Referral Information
Name of Social Worker or Child Life Specialist*
This person will be contacted for confirmation. Please provide doctor’s name if you do not have a social worker/child life specialist.
Title*
Social Worker/Child Life Specialist Email*
Social Worker/Child Life Specialist Phone*
Diagnosis Information
Diagnosis Status*
Diagnosis
Other Diagnosis
Date of Diagnosis
MM slash DD slash YYYY
Date of Relapse (if applicable)
MM slash DD slash YYYY
Patient's Current Status
Patients Interests
Choose all that apply by holding down the CTRL key and clicking
Additional details regarding patient interests or Bear Hug ideas
Additional Information Regarding Child
What is the patient's t-shirt size?*
Family Support Services Request
Additional information regarding financial need
Consent
Name of Individual Completing Application*
Waiver and Release*
I agree to the following:
I give Bear Necessities Pediatric Cancer Foundation and its agents and representatives permission to
• Share information provided in this document with Bear Necessities staff members, volunteers and partners assisting with the fulfillment of the Bear Hug.
• Communicate with the hospital staff to verify information provided in this application and receive or provide periodic updates on the general medical condition and well-being of my Child.
General Release and Waiver of Liability*
I agree to the following:
In consideration of the opportunity to participate in events, activities or customized experiences which are organized or coordinated by Bear Necessities Pediatric Cancer Foundation (“Bear Necessities”) or its Bear Hugs Program (each, an “Event”):

I, on behalf of myself and my minor children for whom I am the parent or legal guardian authorized to act on their behalf (collectively, the “Participants”), agree that Bear Necessities shall not be responsible or liable for, and irrevocably release and discharge Bear Necessities and its affiliates, and their officers, directors, employees and agents, from any claims or liability of any kind arising from any losses, damages or injuries to persons or property of any kind resulting, in whole or in part, directly or indirectly, from attendance at or participation in any Event, including without limitation, during travel or transportation to or from an Event whether by transportation provided by Bear Necessities or any other means. This indemnity and obligation to defend and hold harmless shall survive any termination of this Release or the parties’ activities hereunder.
License to Use Personal Information and Image*
I agree to the following:
I grant permission for Bear Necessities and its contractors and partners to use my child and members of my family’s image, likeness, names, actions and statements made during the course of participation in Bear Necessities Events in any live or recorded audio, video, or photographic display or other transmission, including social media, exhibition, publication or reproduction in any medium or context, and for publicity/promotion by Bear Necessities without further authorization or compensation. I understand that I must provide, in writing to Bear Necessities Program Staff, if I do not grant permission to use and/or publish my child's name, photograph and testimonial statements in all media and types of advertising for promotion and fundraising ventures, publications and services of Bear Necessities and Partners.
Age Verification*
I declare the following to be true:
I represent that I am at least 18 years of age, have read and understand and agree to the foregoing Release, and am competent to execute this Release, and that I am the parent or legal guardian authorized to act on behalf of each minor child listed above.

Bear Hugs Submission - Self Referral

Home Address

Guardian Information

Hospital Referral Information

Diagnosis Information

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