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Harper's Warriors Care Package Application
This application is to request a care package for a child facing surgery. Please read each question carefully and answer completely.
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1.
Recipient’s name and date of birth:
(Required.)
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2.
Address of recipient:
(Required.)
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3.
Parent(s)’ name(s) and contact info:
(Required.)
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4.
Sibling(s) name(s)-
(Required.)
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5.
Number in household-
(Required.)
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6.
Diagnosis/Medical needs-
(Required.)
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7.
In the past 6 months have you received any financial support locally? (Note: your answer will not disqualify your application.) If you answered yes, please share what you have received.
(Required.)
No
Please select yes below and specify.
Yes
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8.
What kinds of things could Harper’s Warriors give in a care package for this recipient?
(Required.)
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9.
Tell us about the nominee.
(Required.)