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F U N D

Brain Cancer ribbon

VICTORIA

R O S E

FINALFINAL_withpalepurplecoloredBR

Bringing smiles to cancer patients

is our thing.

Uplift Package Application

Please Note: Our UPLIFT Program will be temporarily delayed from August 20 through November 1 as we prepare for our 14th Annual Fall Benefit, “Team Maisy.”

We will not forget about you or your loved one during this difficult time and will get back to you as soon as we can. We sincerely apologize for the delay and appreciate your patience and understanding as we work to make this year's event a success. Thank you!

Heartstogether

PACKAGES OF HOPE

Domestic shipping to U.S. only

Apply

First name

Last name

Patient's Full Name

Patient's Age

Home Address

Home Address line 2 (optional)

City

State (e.g., NY)

Zip code

Email

What type of cancer was the patient diagnosed with?

Anything he/she is into right now (Movie, TV show, character, art, etc.)

What best describes this cancer patient? *

Current Patient

In Remission

What hospital/facility is he/she a patient at? *

His/her Doctor's full name *

Please share any social media accounts of yours or your loved one (optional)

Any other comments regarding the patient (optional)

A professional medical document from a licensed physician verifying your or your loved one's cancer diagnosis.

The document must clearly include the patient's name and cancer diagnosis.

I certify that all the information I provided is accurate and correct *

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THANK YOU TO OUR PARTNERS

ONE SMILE

Monroe

LIGHTS

Help us UPLIFT patients spirits with your monetary or in-kind donation today!

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