We want to give you the gift of
music and art

GIFT REQUEST ELIGIBILITY & INSTRUCTIONS

Eligible patients include children and young adults (between the ages of 10-21**) who have been diagnosed with cancer or other life threatening condition within the last 12 months and are receiving treatment. 

Parents, legal guardians or a medical professional can complete the required information on this form to ensure timely processing of your gift request. Please answer all questions on this form.

Upon receipt of your Gift Request Form, a representative from Alyssa Alvin Foundation for Hope will contact you within two
weeks to discuss your request. One of the Executive Officers and/or Board Members will personally deliver your gift.

Our mission is to enrich the lives of young patients diagnosed with cancer or other life threatening condition through the enjoyment and performance of music and visual arts.

Patient Name: *
Patient Name:
Gender: *
Date of Birth: *
Date of Birth:
Address: *
Address:
Phone Number: *
Phone Number:
Additional Phone Number:
Additional Phone Number:
Parent | Guardian Name: *
Parent | Guardian Name:
Date of Diagnosis: *
Date of Diagnosis:

** - Effective 7/11/16