Child Information

Child’s Name

Child’s Age

Child’s Date of Birth

Child’s Gender
MaleFemale

Does the child have siblings?
YesNo

Please list the name, and age for each family member.

Is the child actively receiving treatment?
YesNo

Child’s diagnosis & when they were diagnosed

Summary of the child’s treatment

Where is the child being treated?

Can the child be around groups of people?
YesNo

What would be your child’s ideal party theme? (We cannot guarantee a theme, but we will do our best! i.e. sports, princesses, etc. )

Does your child have any physical restrictions? If so, please describe. (i.e. can they be outdoors?)

Parent’s Information

Parent’s name

Parent’s email

Parent’s phone

Parents complete mailing address

Parent’s social media account URLs

Does the family live in the US?
YesNo

If living in the US, what state do they live in?

What has been your biggest challenge and need with your fighting against childhood cancer?

Are you a military family?
NoActiveReserveVeteran

Who is nominating the child?

How did you hear about Leia’s Kids?

Please upload a picture of your warrior here

Social worker name, email and number

This information is used solely for data collection and program expansion purposes. Your response will remain confidential and will not impact your eligibility for assistance.

1. Household Income

What is your estimated annual household income??
Under $25,000$25,000 – $49,999$50,000 – $74,999$75,000 – $99,999$100,000 – $149,999$150,000+

Estimated Household Income After Diagnosis:

2. Household Size

How many people currently live in your household?
12345+

3. Financial Impact of Cancer

Has a cancer diagnosis impacted your household financially?
If so, please describe how (e.g., loss of income, increased medical expenses, caregiving responsibilities, etc.):

Has a parent/caregiver stopped working or reduced hours due to your child’s illness?
YesNoReduced Hours

4. Financial Assistance

Are you currently receiving any financial assistance? (Check all that apply)
MedicaidSocial Security Disability (SSI/SSDI)Food Stamps/SNAPHousing AssistanceNon Profit AssistanceOther

5. Financial Challenges

Have you faced any of the following financial struggles due to your child’s illness? (Check all that apply)
Difficulty paying rent/mortgageUtility shutoff noticesCar payments or transportation issuesMedical debtBankruptcy or eviction riskOther

6. Grant Use

How do you plan to use this grant? (Check all that apply & explain below)
Medical expenses not covered by insuranceTravel/lodging for treatmentsMortgage/rent assistanceUtilities (electric, water, etc.)Groceries/food supportChildcare for siblingsEducational support (tutors, online schooling, etc.)Funeral/bereavement expenses (if applicable)Other

Additional Explanation (if needed):