Name of Recipient*
First
Last
This is the individual referred to the Breathing Room Foundation for support.
Your Name* Name of the person completing this form
Relation to the Recipient* Self (You are the recipient) Parent Grandparent Spouse Other
If other, please specify
Address*
Primary Phone*
Alternate Phone
Email* Alternate Contact Person (someone to contact if you are unavailable)
What is their relation to you?
Alternate Contact Phone
Please give us a brief explanation of your current situation (type of cancer, how is your treatment going, any specific details about your family that you feel are important for us to know).*
Holiday Outreach Program Do you wish to participate in Breathing Room Foundation's Holiday Program?* Holiday gifts will be chosen for your children using the information given in the series of questions below.
What holiday do you celebrate?* If other, please list here:
Photo Release* We would love for you to share a family photo with us.
Please check the appropriate selection below to give BRF permission to use your child/family’s photo in our marketing materials (website, presentation, newsletter…).
Limited use of photo release* Please specify in this space how you would prefer photos to be used in our website, social media marketing initiatives, and/or in our printed materials.
Family Information How many adults are living in the home?*
Information about adults in the home* Please list the names, ages and relationship to recipient for each adult living in the home.
How many children (18 and under) live in your home?* First child (18 & under) Child must be living in the home.
Name of first child (18 and under)*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy....... Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character.
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Choose one Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores* Check all that apply.
If other, what store?
Second child (18 & under) Child must be living in the home
Name of second family member*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy....... Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores Check all that apply.
If other, what store?
Third child (18 & under) Child must be living in the home.
Name of third child*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy....... Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores Check all that apply.
If other, what store?
Fourth child (18 & under) Child must be living in the home.
Name of fourth child*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy....... Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores Check all that apply.
If other, what store?
Fifth child (18 & under) Child must be living in the home.
Name of fifth child*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy.......* Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores Check all that apply.
If other, what store?
Sixth child (18 & under) Child must be living in the home.
Name of sixth child*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy....... Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores Check all that apply.
If other, what store?
Seventh child (18 & under) Child must be living in the home.
Name of seventh family member*
First
Last
Relationship to recipient:*
Age*
Additional Age Information Ex: Number of months if an infant or other info as needed.
Gender*
Favorite Color:*
Favorite character, actor, singer, animal, etc.
Tell us a little about your child. Does he/she enjoy....... Choose all that apply.
Any additional details Favorite sport, sports team, and/or player
Specific doll, game, books, toy or character
Tell us anything that will help our shoppers. Please remember, no high priced gifts can be promised.
Video Games - additional Information needed What game system do you own? Suggested games?
***We cannot provide games systems or other electronics devices. However, we can provide a game for a system that you own.
Clothing* Does your child need new clothing
Yes, we would like to receive new clothing and will give sizes below No, thank you but we are ok.
Give specific details to help our shoppers. What is needed?
Style - sweatpants/shirts, dresses, jeans, etc.
We cannot promise high priced brands.
Shirt size Please specify child or adult size
Pant size Please specify child or adult size
Shoe size
Child's favorite stores Check all that apply.
If other, what store?
Additional Family Information Although BRF's Holiday Program focuses on the children in the home, we want to be sure everyone feels the love and support of the Breathing Room family.
How many adults (19 & older) are living in the home?*
Please list name, age, relationship, and clothing size for each adult in the home.* Although the Holiday Program focuses on the children, we always want to be sure everyone in the household feels the love and support from BRF.
Where does your family shop for groceries and necessity items?* Tell us about your family's favorite activities and/or outings.
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