Request a Care Package

The Hogfarmers Charitable Foundation is a nonprofit organization whose mission is to help children and families affected by childhood pediatric cancer. To this end, The Hogfarmers conduct programs and activities for cancer-fighting youth.

Care Package Eligibility:

1. The spirit and intent of the Hogfarmers Charitable Foundation's mission statement must be met by the applying family

2. The child in question must be between the ages of Infant to 18 years.

3. The child in question MUST be in active treatment.

State of Residency: What state do you currently live in?

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Active Treatment Confirmation: Care Packages are a limited service offering

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Essential Details

Child's Full Name: Please enter your child's full name

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Child's Birthday: Please enter your child's date of birth

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Primary Phone: Please enter the primary contact phone number

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Primary Email: Please enter the primary email that will be used for all communication

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Primary Address: Please enter your primary address

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Shipping Address Differs: Please check this in order to use a different address for shipping to

Type of Caner: Please enter the specific type of cancer the child is being treated for

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Medical History: What Can You Tell Us?

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General Information About Child

Known and Existing Allergies: Please inform us of existing allergies

Contact Information>

Living Arrangement: Please tell us who the child primarily lives with

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Parent/Guardian One: What is the name of the Primary Caregiver

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Parent/Guardian One's Email: What is the Primary Caregiver's email address

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Parent/Guardian One's Phone: What is the phone number of the Primary Caregiver

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Parent/Guardian One's Occupation: What does the Primary Caregiver do for work

Parent/Guardian Two: What is the name of the second caregiver

Parent/Guardian Two's Email: What is the second caregiver's email address

Parent/Guardian Two's Phone: What is the phone number of the second caregiver

Parent/Guardian Two's Occupation: What does the second caregiver do for work

Permissions Granted>

Privacy & Sharing Acknowledgement: What will you allow us to share? (Please click all that apply)

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Social Media Usage: May we use content from your child's social media?

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How did you hear about us?: Please be specific

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Do you have a Case Worker?: Yes or No

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Case Worker's Name?: Please tell us the name of your case worker

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Case Worker's Email?: Please provide your case worker's email address

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Case Worker's Phone?: Please provide your case worker's phone number

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What hospital you do primarily use?: Please give use the name of the hospital

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What city and state is this hospital located in?: Please give use the location of the hospital

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Are you a Facebook User?: Please answer Yes or No

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Your Facebook URL: Please provide your Facebook URL

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Support Specifics>

Your support preference?: Please select all that are preferred

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Your gas station preferences?: Please list all that are preferred

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Your grocery store preferences?: Please list all that are preferred

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Your preferences for gifts to pass the time?: Please list all that are preferred

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Would you like gas cards instead of toys?: Please select Yes or No

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