Family Joy Request

For children facing serious illness to request joyful experiences, creative healing sessions, or legacy celebrations. Not a HIPAA-covered entity • Minimal info collected

1) Child & Family Information

Child's Full Name *

Date of Birth *

Primary Diagnosis / Health Concern *

Pronouns

Current Treatment Site (Hospital/Clinic & City, State) *

Languages Spoken at Home

Parent/Guardian Name(s) *

Relationship to Child *

Best Phone *

Email *

Address *

City/State *

ZIP *

2) Eligibility & Program Fit

Brief description of child's current health status and needs

2-4 sentences

3) Sibling(s) & Family Joy Profile

How many siblings are in the home?

How do siblings react to visits with medical staff?

Does the focus child enjoy spending time with siblings?

Please list any sibling interests or favorite activities:

Describe the family dynamic. What is important to you as a family?

Please list who will be the primary caregiver present during Joy programming:

What language(s) does your family speak at home?

What language(s) does your focus child communicate in?

If English is not your family's primary language, do you require the assistance of a translator?

4) Access Needs

Does the child use any assistive technology devices (i.e. communication board, wheelchair)?

Will an interpreter (ASL or Language) be required for any Joy activities?

Is there any other information that would be helpful in ensuring your child/family has a positive experience?

5) Liability Release & Indemnification Agreement

Please read the agreement below and complete all signature fields. Typed names act as electronic signatures.

By submitting this form, I acknowledge that I have read and understand the liability release and indemnification agreement. I agree to release Trevor's Joy Inc. from any liability arising from participation in the programs and activities.

Patient Name *

Names of those participating in the Request

Participant #1 (Name) *

Participant #1 Date *

Participant #1 Signature (typed) *

Participant #2 (Name)

Participant #2 Date

Participant #2 Signature (typed)

Request/Program (optional)

Parent/Guardian Name (if applicable) *

Date *

Parent/Guardian Signature (typed) *

Reader/Translator Name (if applicable)

I have read and agree to the Liability Release and Indemnification Agreement above. *

You'll receive an email copy of your submission. Submit completed application via this form or email support@trevsjoy.com. Data is stored securely and used only to deliver services. You can request deletion anytime.