Make A Child Smile

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Celebrating 12 YEARS of making kids smile!!!

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ONLINE APPLICATION

Attention: DO NOT navigate away from this page and then click the "Back" button on your browser, or else this Form will give you an error when you submit it. If needed, "Refresh/Reload" this page and make sure you don't navigate away from it until it's submitted.

**Important** - If you haven't written a Biography about your child yet, please write one before proceeding.

* - indicates a required field
Please DO NOT use ALL CAPS (upper case) when writing

Child's Information

First name *
Middle name *
Last name *
Address to Child's CaringBridge website or other *	This website will be posted on your child's MACS page! *Write* FULL link please. If CarePages, add the link followed by the CarePage Name in parenthesis. i.e. www.carepages.com (johnsmith)
Age *	years old
Date of birth *
Main diagnosis *	Please list the Main diagnosis using the medical name for it. In case of heart defects, write "Multiple Heart Defects" and then use the form below to list them all

Other diagnoses

If child has more than one diagnosis, list the other ones here

Biography *

Biographies need to have a minimum of 3,000 characters and no more than 7,500 characters. Below the text box you will see your text characters being counted as you type (or paste) the biography.

Begin story from birth, then signs of illness,
diagnosis and what he/she has been through until today.

CHARACTER COUNT: 0 characters
(If the number of characters don't show after you paste,
just put a letter or a space at the end of your text and then erase it)

Child's Interests *

i.e. favorite cartoons, toys, hobbies, things to do...
This helps people know what do send if they wish to mail a gift!

Abilities *

See		special notes
Hear		special notes
Talk		special notes
Walk		special notes
Use hands		special notes

Family Information

Checkbox selected - display name on your child's MACS page Checkbox not selected - do not display name on your child's MACS page
Father's full name *
Mother's full name *
Stepfather's full name (if applicable)
Stepmother's full name (if applicable)
Marital status (from biological parent)
Marital status (at present time)
Guardian's full name (if applicable)
Home address *
City *
State *
Zip *
Home phone *
Cell phone *
Work phone (father)
Work phone (mother)
E-mail * (check for typos)
Religion (optional)
Please list any holidays for which you do not wish to receive mail i.e. Thanksgiving, Christmas, Easter...

Siblings' Information

Only child
Expecting Baby due

Gender	Name	Age	Date of birth

Other/more siblings

Siblings' interests

Please list Interests for EACH young sibling separately.
This is optional for siblings older than 18 years of age.

Doctor's Information (doctor associated to child's main diagnosis)

Doctor's name *
Doctor's phone *
Nurse's name *

Additional Information

Preferred date to be featured

Mailing Address where your child will be receiving MACS Mail *
(If you choose to use your Home Address, then just write "Home Address" below.
If you will be renting a P.O. Box, then just write "Will be renting a mailbox", unless you already have one.)

Questions / Comments

Submitted by * If other

	I am not this child's parent or legal guardian, but I have permission from this child's parent / guardian to submit this form. (We may request that a written authorization (notarized letter) from actual parent be sent to us).
Please type these letters below before clicking on "submit" *

**ATTENTION**
BEFORE you click on "submit", make sure you have
filled out all required fields marked with a red *, or else
you may lose all info and will have to start all over again!

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	La'Cyrus P , age 14 Acute Disseminated Encephalomyelitis Aug 19th, 2009 Alexa B , age 11 Medulloblastoma Aug 6th, 2009 Seth H , age 12 Acute Lymphoblastic Leukemia May 31st, 2009

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