Trevor's Joy Gift Basket Options

Please complete the patient and family information below, then choose the basket option you feel would be most meaningful for your child.

Patient Data

Please provide information about your child (the patient).

Parent's First Name *

Parent's Last Name *

Parent's Contact *

Format: (000) 000-0000

Email *

Street Address *

Street Address Line 2

City *

State / Province *

Postal / Zip Code *

Patient's First Name *

Patient's Last Name *

Patient's Date of Birth *

Patient's Age *

Diagnosis *

Total Number of Adults in Home (18+) *

Total Number of Children in Home (under 18) *

Tell Us About Your Child

Tell us about your child and what brings them joy! *

Gift Basket Options

There are five types of baskets below to choose from. Please select ONE option under the type of basket you would like to receive.

Which basket is best for your child?

Arts & KeepsakesCreativity . Legacy . Memories.

Out & About AdventuresShared Experiences . Time Together.

It's a Great Day to Play #1Play . Independence . Fun at Home.

It's a Great Day to Play #2Play . Group . Fun with Friends.

Personalized JoyUnique Wishes.

Based on your selection above, is there anything specific you would like us to know that has not already been identified on this form?

Our Promise: Families Never Pay / Handled with Care / Respect & Privacy

We are committed to bringing joy and comfort to every family.

Waiver Section

Photo & Story Permission (Optional)

YES – I give permission for photos/videos of the recipient to be used for educational, promotional, or fundraising purposesNO – I do not give permission for photos/videos to be used

Preferred name to use (if different)

By signing this form, I acknowledge and agree that:

Trevor's Joy Inc. provides gift baskets and experiences as charitable acts intended to bring joy and encouragement.
Some items included in baskets may be donated or provided by community partners.
I accept full responsibility for supervising the child/recipient while using any items or participating in any activities included in the gift basket.
I release and hold harmless Trevor's Joy Inc., its founders, volunteers, donors, and partners from any liability arising from the use of items provided in the gift basket or related experiences.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Signature (typed) *

Date *