Nominate a Parent

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
Memory recipients must be able to communicate the wish and comprehend/participate in the memory experience
Memory recipient must have at least one child under the age of 18 at the time of referral

Nominate a Parent

If you would like to nominate someone or yourself please use this form to begin the process.

Your Contact Information
Name of Person Completing Form
First Last
Relation to Applicant
Phone Number
Email
How did you learn about Memories for Kids?*
Is the Applicant aware that you are nominating them?
- Yes
- No
Cancer Patient Information
Applicant's Name
First Last
Applicant's Spouse/Significant Other
First Last
Applicant's Address
Street Address City State ZIP Code
Applicant's Phone Number
Applicant Email
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
Are There More Than 4 Children?
- Yes
- No
Additional Children
Names and Ages of Additional Children

Nominate a Parent

Nominate a Parent

Your Contact Information

Cancer Patient Information

Cancer Information

Children