We want to give you the gift of
music and art

GIFT REQUEST ELIGIBILITY & INSTRUCTIONS

Eligible patients include children and young adults (minimum age 10 - maximum age 21**) who have been diagnosed with cancer or other life threatening condition within the last 12 months and are currently receiving treatment. In addition, gift recipient must be undergoing treatment within a 50 mile radius of Chicago, Illinois.

Parents, legal guardians or a medical professional can complete the required information on this form to ensure timely processing of your gift request. Please answer all questions on this form. Note that submission of a gift request implies positive consent for posting of a blog along with pictures on our website regarding the delivery of the gift to the recipient.

Upon receipt of your Gift Request Form, a representative from Alyssa Alvin Foundation for Hope will contact you within two weeks to discuss your request. One of the Executive Officers, a Board Member, or a volunteer will personally deliver your gift.

Our mission is to enrich the lives of young patients diagnosed with cancer or other life threatening condition through the enjoyment and performance of music and visual arts.

Patient Name:

First Name

Last Name

Gender:

Male

Female

Date of Birth:

MM

DD

YYYY

Address:

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number:

(###)

###

####

Additional Phone Number:

(###)

###

####

Email:

Parent | Guardian Name:

First Name

Last Name

Language Spoken at Home:

Date of Diagnosis:

MM

DD

YYYY

Diagnosis:

Name of Physician:

Name of Hospital where treatment is received:

Name of Person/Medical Professional that referred you to us:

Tell us about your interests and what you like to do:

Gift Requested (Maximum gift value up to $250). Please specify the instrument or art accessories desired. ***Alyssa Alvin Foundation for Hope does not supply gift cards.

** - Effective 7/11/16

Request a Gift

We want to give you the gift ofmusic and art

GIFT REQUEST ELIGIBILITY & INSTRUCTIONS

We want to give you the gift of
music and art