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
Patient is being treated for pediatric cancer
Patient is a resident of Illinois and/or is being treated at a hospital located in Illinois
I am the Parent/Guardian of the Patient; or I am the Patient and 18+ years old
Thank you for your interest. You are not eligible to receive a Bear Hug at this time. Please visit www.bearnecessities.org for information about our various programs and events. Please contact [email protected] if you have any questions.
Patient First Name* Patient Last Name* Date of Birth*
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State / Province / Region
ZIP / Postal Code
CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands
County* Name of Hospital Where Receiving Treatment*Hospital IDAdvocate Children’s Hospital – Oak LawnAdvocate Children’s Hospital – Park RidgeAnn & Robert H. Lurie Children's HospitalCardinal Glennon Children's HospitalCarle HospitalCentral Dupage HospitalChildren’s Hospital of Wisconsin - Milwaukee, WIHSHS St. John's Children's HospitalJohn H Stroger Cook County HospitalLightways HospiceLoyola Ronald McDonald Children’s HospitalNorthwestern Medicine Proton CenterRush Presbyterian St. Lukes Medical CenterSt. John’s HospitalSt. Jude Children's Research Hospital - Memphis, TNSt. Jude Midwest AffiliateSt. Louis Children's HospitalUniversity of Chicago Medicine - Comer Children's HospitalUniversity of Illinois at Chicago (UIC)UWHealth Kids American Family Children’s Hospital- Madison, WIOtherOther Hospital ID Gender*GenderMaleFemaleNon-binaryTransgenderRace*RaceAmerican Indian or Alaska NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian or Other Pacific IslanderWhiteMulti-RaceOtherOther Race Name of school patient attends Patient Email (if applicable or 18+)
Patient Phone (if applicable or 18+)Patient Website Guardian InformationNo. Parents/Guardians Living with Child*12Parent 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*12345678910111213141516171819Sibling Names, Gender and Ages Example: John M 12; Sarah F 9; Lillie F 3mosLanguage(s) spoken at home (include all)* Approximate Household Income*Less than $14,999$15,000 - $29,999$30,000-$44,999$45,000-$59,999$60,000-$99,999$100,000-$149,999$150,000 and aboveUnknown at this time(This information is used for data collection; financial information is not a qualifier to receive support from Bear Necessities.)Hospital Referral InformationName 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 WorkerChild Life SpecialistNurseDoctorOther ProfessionalSocial Worker/Child Life Specialist Email*
Social Worker/Child Life Specialist Phone*
Diagnosis InformationDiagnosis Status*Initial DiagnosisRelapseDiagnosisSelect OneLeukemia ALLLeukemia AMLBrain TumorLymphomaNeuroblastomaOther Diagnosis Date of Diagnosis
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Date of Relapse (if applicable)
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Patient's Current StatusIn hospitalHomePatients InterestsAmerican Girl Dolls/ToysGaming SystemsMuseum/AquariumSpa/SalonShopping SpreesSports EventsTheater/Concerts/Show ExperienceWater Park/Hotel StayBedroom MakeoverElectronicsOutdoor Equipment (Bike, Bounce House)Choose all that apply by holding down the CTRL key and clickingAdditional details regarding patient interests or Bear Hug ideasAdditional Information Regarding ChildWhat is the patient's t-shirt size?*Youth XS (2/4)Youth S (6/8)Youth M (10/12)Youth L (14/16)Adult SAdult MAdult LAdult XLAdult XXLFamily Support Services RequestGas/Grocery Gift CardsUtility Bill PaymentUnsureN/AAdditional information regarding financial needConsentName 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.
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55 West Wacker Dr, Suite 1100Chicago, IL 60601
Serving Golisano Children's Hospital& greater Southwest FloridaContact: [email protected]
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