Please read the "Guidelines for Parents" before completing this form. ALL boxes must be completed or application may not submit properly. Place NA in areas that do not pertain to your child.
Full name of child :
Birthdate of Child :
Main Diagnosis (please use medical terms,
DO NOT list a webpage address here):
Date of Diagnosis:
*REQUIRED FOR QUILT! No exceptions*
Webpage for child giving updates on condition
(Facebook, Caringbridge, etc.)
* All information below will be kept private *
Full Name of Father:
Full Name of Mother:
City, State and Zipcode:
Address where quilt should be mailed (if different than above):
Phone Numbers:(Home & Cell)
Correct Email address:
Alternate Email address:
Form submitted by: (Must be Parent or Legal Guardian)
How did you hear about Love Quilts USA?
Has your child received a quilt in the past from another group online or locally?
Child's Interests and favorite color :
Biography of Child
Begin story from onset signs of illness, diagnosis and what he/she has been through until today. Please write at least 3 paragraphs. This information will be posted on the Love Quilts USA webpage created for your child. If you have another site where your child is already featured such as Facebook and there is a full bio listed please direct us to that site.