SuperHero Pack Nomination

Do you have a child who is the sibling to a medical child and you feel would benefit from a surprise package? Please register them to receive a SuperHero Pack. The information provided will only be used to create a SuperHero Pack that is fitting for your child and to deliver it to them.

* Indicates required field

Parent/Guardian First and Last Name *

First

Last

Parent/Guardian email address *

Parent/Guardian Phone Number *

County *

Mailing Address of SuperHero Siblings *

Line 1

Line 2

City

State

Zip Code

Country

Medical Child's First and Last Name *

First

Last

Choose the Hospital the child will be located at *

Cook Children's Fort Worth Texas Scottish Rite Dallas Children's Dallas

Please list all SuperHero Siblings Name, Age, Gender and interests *

Please tell us anything extra about your SuperHero Sibling children that may help us in filling their SuperHero Pack *

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

Electronic Signature *

Photo Release *

Submit