Laptops are donated based on availability.  If you are unsure if a laptop is available for donation to a patient, please contact Jenny Scott at jscott@heroesforchildren.org.  All laptops are used, usually more than two years of age. Once donated to the patient, the laptop is no longer the responsibility of Heroes for Children and will not be repaired if a problem occurs.  Please do not apply for a laptop without speaking to someone at Heroes for Children in advance!

 

Child Info:

Name

Date of Birth

    

Parent Name

Street Address

City

State

Zip Code

Telephone Number

E-mail Address

Cancer Diagnosis

Date of Diagnosis

    

Referring Doctor/Health Care Professional

Telephone Number

 

Ethnicity

 

Current Level of Function (Select only one.)

Independent

Wheelchair-bound

Bed-bound

Is child currently hospitalized?

Expected Length of Stay

No                    Yes

Check all of the following that apply:

No Special Needs

Intravenous Fluid/Medication Requirement

Oxygen Requirement

Hospice Care

Relapse

Bone Marrow Transplant?

Date of Transplant

No                    Yes

    

 

 

Laptop Info:

Describe patient's need for a laptop

Preferred date of delivery

Preferred Method of delivery

 

 

Send Laptop to: (leave blank if same as Family address above)

 

Street Address

City

State

Zip Code

 

 

 

Social Worker:

Full Name

 Hospital

 


     

 
          

Heroes for Children is a non-profit 501 (c) 3 organization.

All donations are tax deductible.