Go Gold Application

Childhood Cancer Awareness Month is around the corner and we need your help identifying a families who has a child being treated for cancer at your hospital as a “Go Gold” Family. This family will receive a special care package from our team that includes a financial assistance check and some Heroes for Children goodies to be sent to their home address or hospital room in September. A select number of families will be selected across the state.

Go Gold Nomination Rules:

Nominations will be open now through August 30th.
Assistance amount will not be deducted from hospital’s budget
Normal wait times between patient’s applications do not apply
Patient must be between the ages of 0-22 years old and be in active treatment or recently lost their battle
Each patient/family who is selected as “Go Gold Family” will receive $200 check
Please do not promise a family/patient anything to avoid miscommunications
Our team will review the applications, and by Monday, September 6th, we will announce the families selected to participating hospitals and packages will be shipped to families.

Patient First Name

Patient Last Name

Patient Birthday

Guardian Address

Guardian Phone

Guardian Email

Tell us why this family should be selected for additional funding through our Go Gold program.

Is the address above where we send the check to? If not, please provide a secondary address.

Name of Hospital

Name of Social Worker

Is the guardian employed?

Yes

Guardian Income Range

0-24,999

25,000-49,999

50,000-99,999

100,000+

Please upload a photo of this child/family that has been provided by the family.

Does the guardian give permission for Heroes for Children to use the photograph provided for marketing materials to promote our mission and the Go Gold program?

Yes