NOTE: The submission button is not working at the moment.  If you wish to have your child featured, please copy and paste the info into a Word document or email and complete.  We hope to have this resolved shortly.  Thanks!

Thank you so much for your patience.  When your child's story is ready to be added to our site, we will email you to check over the

information online and to make any corrections that might be needed.

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Tumbleweed Foundation Parental Consent Form

If any spaces with '*' are left blank, we will not be able to feature your child on our site.  You must complete this application completely to be considered for our program. 

Children must be 18 months - 19 years to be featured, as per our by-laws. 

Thank you!

 

Today's Date*     

How did you hear about us?     

Child's Name*                      Birthdate             

Diagnosis*                  

Limitations                                               

Skill Level:    
    

Web Site Address    

Child's Interests & Favorite Things*       

Sibling Information: (Only include siblings 19 years of age or younger)*

Sibling One: M   F    Birthdate:  

Interests:

Sibling Two: M   F    Birthdate:  

Interests:

Sibling Three: M   F    Birthdate:  

Interests:

Sibling Four: M   F    Birthdate:  

Interests:

If Child has more than four siblings, please email Mary with the additional information.

Pets - Name and Type of Pet:

 

Anything else you would like us to know about your child:

Address where small gifts can be sent (We strongly Urge you to obtain a PO Box for about a 3 month period)*

:

Do you wish to participate in our Wish Program*? Y   N

 Child's Wish:

 

Mother's Name*:  
Father's Name*:

Home Address (Confidential)*:

 Home Phone (Confidential):

List 2 Email Addresses (Please be sure you give us

TWO email addresses, in case one does not work.)*: 

                                                                           

Medical Information *: WE MUST HAVE A LETTER FROM YOUR CHILD'S DOCTOR CONFIRMING DIAGNOSIS OF YOUR CHILD'S ILLNESS BEFORE YOUR CHILD WILL BE FEATURED.  THIS LETTER MUST BE ON OFFICIAL LETTERHEAD, and received directly from THE DOCTOR'S OFFICE.  LETTER SHOULD BE MAILED TO

P.O. Box 183, EIGHTY FOUR, PA 15330

Doctor's Name*:            

Phone Number with area code*:   

Doctor's Street Address*:  

*I hereby give permission to Mary Kitchen and/or Judy Levy to contact the above Physician to verify illness      

Name of Most used Hospital*:          Hospital Phone*:     

*I hereby give permission to Mary Kitchen and/or Judy Levy to contact the above Hospital to verify illness 

Bank Fund Info (If Any):

Include Fund Info on Feature Page?  Yes   N

Please Provide Us with a Short (2-3 Paragraph Maximum) biography for inclusion on Web Site*:

*CHECK LIST - The following items must be COMPLETED and RECEIVED PRIOR to acceptance into the program.

Child's photo is being sent via snail mail with this signed consent form

Our primary physician's letter verifying illness is being sent directly to the Tumbleweed Foundation from the Doctor's office.

For privacy and security reasons, I/we have included a mailing address that is NOT our physical living address.  See release below.

I have printed out a copy of this form and SIGNED and DATED the application and

I will mail it via snail mail through the POST OFFICE today to The Tumbleweed Foundation,

Attention: Featured Child, P.O.Box 183, Eighty Four, PA  15330  

** We CANNOT feature your child if we do NOT have a signed PRINT OUT OF THIS PAGE!

I/We have included any and all sibling information

I/We have answered all questions honestly and to the best of my/our ability

 

I hereby submit my child for inclusion on the Tumbleweed Foundation’s web site.  I acknowledge that my child has a serious illness or injury and I give my permission to Mary Kitchen and Judy Levy of the Tumbleweed Foundation to post the story, photo, and mailing address of my child (as named on this form) on the Tumbleweed Foundation web site.  I also authorize Mary Kitchen and Judy Levy of the Tumbleweed Foundation to use my child's picture and story on any of the organization's promotional flyers and/or news releases, if a need arises.  I assume the entire responsibility and liability and hold harmless the Tumbleweed Foundation and its founders Mary Kitchen & Judy Levy for any and all loss, expense, damage, demand, or claim.  I understand that The Tumbleweed Foundation is not responsible for mail sent to me by people who visit their website and read my information there.  I also understand that The Tumbleweed Foundation is not required to feature my child and may remove our story at any time, if they deem it necessary.  (Please PRINT THIS FORM BEFORE YOU HIT SUBMIT, sign below after printing to make it legal and snail mail it to the address at the bottom of the form!) 

WHEN PRINTING PLEASE SET YOUR PAGE ORIENTATION TO LANDSCAPE, SO NO INFORMATION IS CUT OFF!  THANKS!!!!

 

 

                                                                                                                                               

Signature

                                                                                                                                               

Name (Printed)               Date

Please email us as many pictures as you would like.  We really like to post pictures of the children, so people can get to know them even better.  If you are not the Parent or Guardian of the Child to be featured, we do need that person(s) permission and signature on this form.  Thank you in advance for your cooperation.

Remember:  AFTER emailing, you MUST PRINT

this form (switch print direction to Landscape when printing please) and snail mail it to:

Featured Child

The Tumbleweed Foundation

P.O. Box 183

Eighty Four, PA  15330

Once your child is accepted into our program, the story will be featured on our web site for one month.  As long as we can obtain updates at least once a month, either via email, or through your web site, your child will continue to be included in the "Tumbleweed Kids" section of the Web Site.