Nominate a Parent

Complete the form to nominate yourself or someone else for an unforgettable family memory experience.

Nomination Information

We are currently granting memories in Nebraska and Iowa. If you are interested in opening a Memories for Kids chapter in your area or would like more information regarding this please contact us at info@memoriesforkids.org

Who is eligible?

Memory recipients must have Stage IV cancer or similar as designated by your oncologist.
Memory recipients must have at least one child under the age of 18 in the home at the time of referral.
Memory recipient must be able to communicate the wish and actively participate in the memory experience, unless Memories for Kids is creating a keepsake item.
Options are available for parents in hospice care.
Memory recipient must be a resident of Nebraska or Iowa at time of referral.

"*" indicates required fields

Are you nominating someone from Nebraska or Western Iowa?*

Nominee must be located in Nebraska and Western Iowa.

Yes

Thank you for thinking of Memories for Kids. We currently serve families in Nebraska and Western Iowa. We noticed you indicated that you are outside that area. Before continuing with the application, please reach out to us at info@memoriesforkids.org. Thank you!

Your Contact Information

Name of Person Completing Form*

Phone Number*

Email*

How did you learn about Memories for Kids?*

Are you nominating yourself or someone else?*

Myself

Someone Else

Relationship to Nominee

Is the Nominee aware that you are nominating them?*

Yes

Your Spouse/Significant Other*

Your Address*

Nominee Information

Nominee's Name*

Nominee's Spouse/Significant Other or Alternate Contact*

Nominee's Spouse/Significant Other or Alternate Contact Phone Number*

Nominee's Address*

Nominee's Phone Number*

Nominee's Email Address*

Cancer Information

Type of Cancer*

Stage of Cancer*

Briefly Describe the Applicant's Current Status*

Children

Child 1 Name & Age

Child 2 Name & Age

Child 3 Name & Age

Child 4 Name & Age

Additional Children?

Yes

Names and Ages of Additional Children

Section Break

This field is for validation purposes and should be left unchanged.