Apple a Day Program Application Helping kids stay connected while fighting cancer. Child's Name* First Last AgeYour Name First Last Which program are you applying for?*TampaOrlandoNYCPhoneAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Email* Your relationship to the childTotal family sizeChild's type of cancerAlthough we are considering ways to grow and serve other kids, we currently only work with kids with a pediatric cancer diagnosis. Our love goes out to ALL families fighting disease though!Current status of treatment / expected durationHospital affiliationChild Life Specialist / Social WorkerName First Last PhoneFurther InformationPlease tell us anything you’d like about your child and his/her experience with cancerWhat type of activities and things does your child enjoy? (For example, types of video games, books, sports teams, princesses, Barbies, art, Disney, etc.)What other organizations has your family applied to/previously received support from?How would an iPad benfit your child?Do you have access to a computer at home?YesNoInformation Release*By signing below, I hereby release the rights of this information to be used by Apple A Day Program at any time they may deem it helpful to use in their efforts to raise more money for children and families battling cancer. I understand that my story may be shared via a number of different formats with the public, including written, video, audio, or photographic.Medical Release*By initialing below, I hereby release medical information about my child to Apple A Day, specifically limited to determining eligibility for an iPad. The aforementioned treating hospital representative and/or Children’s Cancer Center Representative is now given my permission to discuss this information about my child with a designated volunteer of Apple A Day. This iframe contains the logic required to handle Ajax powered Gravity Forms.
