Do you know of a pediatric hospital patient celebrating a birthday and would like to send them a box? Please complete the form and we will send them a Birthday in a Box! Have questions? Email celebrate@haleyshappybirthdays.org Patient Name * First Name Last Name Patient's Birthday * mm/dd/yyyy) Gender * Girl Boy Patient's Diagnosis * Where is the patient receiving treatment? (Please list hospital) * Any specific colors, characters or things the patient likes? * Your Name * First Name Last Name Your Email * Relationship to the Patient * Parent/Guardian Grandparent Family Member Friend Patient's Parent/Guardians Name * First Name Last Name Patient's Parent/Guardians Email * Message you would like to include in their birthday card Where should we send the package? * Address 1 Address 2 City State/Province Zip/Postal Code Country Anything else you would like us to know We would love to hear how you found us or heard about us :) * Thank you for requesting a birthday box be sent to your friend or family member. This moment of joy will definitely make their birthday brighter! If you are interested, you can make a donate here to help cover the cost of the box and shipping.If you have any questions please contact celebrate@haleyshappybirthdays.org
