Golden Hero Nomination

Do you have a child who was recently diagnosed with cancer? Please register them to receive a Golden Warrior Package. The information provided will only be used to create a Golden Hero Package that is fitting for your child and to deliver it to them at the hospital.

* Indicates required field

Parent/Guardian First and Last Name *

First

Last

Parent/Guardian email address *

Parent/Guardian Phone Number *

Child First and Last Name *

First

Last

Gender of Child *

Age of Child with cancer *

Childs Birthdate *

Childs T-shirt Size *

Address *

Line 1

Line 2

City

State

Zip Code

Country

County *

Has your child received a firefly box before? *

Choose the Hospital the child will be located at *

Cook Children's Fort Worth Children's Medical Center Dallas

Type of cancer diagnosed with *

Date of diagnosis *

Name of onocologist *

Please tell us anything extra about your child that may help us in filling their Golden Hero Package to better for their needs. Favorite color, character, hobbies, ect... *

Does the Golden Hero have siblings? *

Would you be interested in the siblings receiving a SuperHero Sibling Pack? *

Yes No Maybe in the future but not right now

Please list siblings name, age, gender and special interests *

I agree that I, for myself and children, heirs, executors, administrators and assigns, hereby release, waive, discharge and hold harmless, Bellanne Butterfly Blessings and its successors, assigns, directors, board members, officers, employees and agents from any and all liability, claim and demands of whatever kind of nature, either in law or in equity, which arise or may hereafter arise from any services provided by or on behalf of Bellanne Butterfly Blessings. *

Yes

Photo Release *

Electronic Signature *

Submit