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Keepsake Memory Application

We are honored to work with your family and look forward to creating a special keepsake memory.

Memories For Kids is a memory granting organization for children of parents with Stage IV cancer.

The Medical Form needs to be completed by Physician and sent to Memories for Kids.

Medical Form

Here are a few suggestions for special keepsake options. While this list is not comprehensive, it highlights what many families have found to be memorable. Consider what resonates with you and your loved ones, and let these ideas inspire your decisions.

Special Keepsake Options

~ Keepsake Memory Application ~

Applicant form to request a keepsake memory.

"*" indicates required fields

General Information

Applicant’s Legal Name*

First Middle Last

Address*

Street Address City State ZIP Code

County*

Preferred phone number

Home Phone

Cell Phone

Cell Phone*

Home Phone

Email*

Birth Date*

MM slash DD slash YYYY

Age*

Ethnicity (optional)

Military Veteran*

Yes

No

Branch and Dates of Service

Referred by*

Religious Preference (optional)

Present/Most Recent Employer*

Additional Contact Information

Spouse/Partner/Caregiver or Other Contact Person*

First Last

Relationship to Applicant

Preferred phone number

Home Phone

Cell Phone

Cell Phone*

Home Phone

Address

(If different than above.)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

E-Mail Address*

Employer

The following statements are used for donor information and grant writing purposes and do not impact your eligibility to receive a keepsake memory:

Please check any that apply:

My family qualifies for SNAP benefits.

My family qualifies for Free or Reduced Lunch benefits

My family qualifies for Medicaid Insurance

My family qualifies for WIC benefits.

Applicant has been granted a wish or memory by another organization.

An application has been submitted or pending with another wish granting organization.

If checked, where has it been submitted?

Memory Participants

Number of Participants*

- Children and Spouse/Partner/Caregiver -

Please enter a number from 1 to 10.

Memory Participant 1 - Legal Name

First Middle Last

Memory Participant 1 - continued