If your child will be hospitalized soon, please complete this questionnaire. Once the questionnaire is submitted, Sydney, Carly, and other volunteers will create your customized basket and send it to you.

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* 1. First and last name of child having surgery:

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* 2. Child's Pronouns:

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* 3. Child's Birthday:

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* 4. Child's Grade:

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* 5. Child's Condition/Diagnosis:

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* 6. Parent / Guardian Info (Primary Contact):

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* 7. Parent/Guardian Info:

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* 8. Mailing Address: (Due to current hospital guidelines, we need to send care packages directly to you at your home.)

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