Lap Blanket

Notice: We are currently out of blankets at this time.

Sender
Sender's Details*
First Last
Email*
Recipient
Recipient's Details*
- Same as Sender (Self Referral)
- Detailed Below
Recipient's Name
First Last
Age*
Gender*
Address (For Delivery)*
Street Address Address Line 2 City Province Postal Code
Phone*
Email
Diagnosis*
Date of Diagnosis*

Year
Month
Day
Is the recipient in active treatment?*
- Yes
- No
Additional Details
How did you hear about this program?
Any comments or suggestions to help us improve this program?
I do hereby release and discharge Shine Through The Rain Foundation (STTRF) and its officers, agents, servants, employees, volunteers and affiliates from any and all claims for injuries, including death, damages, property damage, or loss which may have, or may in future, accrue to me as a result of my involvement or participation in any activities associated with this organization. By checking this box you are acknowledging and agreeing to this liability waiver.
*
- I agree
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