Wagon Nomination

To be eligible, the wagon must be intended for a family with a child no older than 21 fighting cancer. We know that long clinic appointments don’t stop after “end of treatment” so we will give a wagon to any family within 5 years of their end of treatment date.

Nomination Form – HYP!

Child's Name(Required)

First Last

Relation to Child(Required)

If Other, please specify:

Child's Birthday(Required)

Child's Diagnosis(Required)

Diagnosis Date(Required)

Treating Hospital(Required)

Child's Story

Child's Favorites(Required)

Color, characters, toys, etc.

Does the child have any siblings?

Please include their name, age, and favorites.

Your Name(Required)

First Last

Parent/Guardian Name

If applicable

First Last

Phone Number(Required)

Email(Required)

Shipping Address(Required)

Street Address Address Line 2 City State ZIP Code

Shipping address is:

Child’s home

Hospital address

Include lap tray?(Required)

Yes

Include portable charging brick?(Required)

Yes

How did you hear about us?

Allow child's photos to be shared online in an effort to raise more money so more kids can get wagons?(Required)

Yes

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Phone

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