All information is required unless it does not apply to your family. Please put N/A in the boxes that do not apply. This form must be complete to be considered for a quilt. Any questions can be emailed to us at Cyberfogie@aol.com.
No information will be posted on the Love Quilts website with the exception of the first name and last initial of the child, the birthdate of the child, the main diagnosis of the illness and the biography. All other info will be kept private and only given to those that will be finishing and mailing the quilt to your child. If the parent wishes the child's website to be listed on their Love Quilts page permission must be emailed to me. If no permission is given the website will not be listed.
Child's Information
Full name of child (First, Middle and Last):
Birthdate of Child (Month, Day, Year):
Main Diagnosis (please use medical names,
DO NOT list a webpage address here):
Date of Diagnosis:
Other Diagnosis:
*REQUIRED FOR QUILT! No exceptions*
Webpage for child giving updates on child: (such as caringbridge etc. or any site that features your child with a bio such as Facebook, Hugs and Hope, etc.
Family's Information
* All information below will be kept private! *
Full Name of Father (First and Last):
Full Name of Mother (First and Last):
Last name of the family (if different from the child's):
Siblings and Birthdates (Example:
Bob, 1/1/90, Sue, 2/2/92 etc.):
Home Address:
City, State and Zipcode:
Snail mail address where quilt should be mailed (if different then above):
Phone Number (only used if we are unable to contact you via email and will be kept private):
Correct Email address for us to use (Kept Private):
Alternate Email address for us to use if
main address doesn't work for some reason:
Form submitted by: (If submitted by anyone other then the parent permission must be received from the parent before child is featured. Please DO NOT put N/A here, for legal reasons this must include the parents name who submitted the form.)
Quilt Information
Child's Interests and favorite color (Please make this listing as detailed as you can):
Biography on Child
Begin story from onset signs of illness, diagnosis and what he/she has been through until today. Please write at least 3 paragraphs. This information will be posted on the Love Quilts webpage created for your child. If you have another site where your child is already featured such as Hugs and Hope etc. and there is a full bio listed you can just direct me to the page your child is on. Please make sure you direct me to the exact page and not just the homepage of the site.
Please read this entire page in full before submitting your child to receive a quilt from Love Quilt!
Thank you for your interest in submitting your child to receive a quilt from Love Quilts. By submitting this form you are agreeing to allow Love Quilts to feature your child's picture and basic information on our site (personal information such as your last name, location, email address etc. will never be posted by Love Quilts). Please note, form must be filled out by a parent or guardian!
Once the form is received it will be reviewed and we will then decide if the child fits all the requirements to receive a quilt from Love Quilts. You will be notified by the email address you provide to us if your child is approved and you will be given an approximate time frame for the quilt to arrive. Please note it can take 1-12 months to get a quilt depending on the child's illness and theme choice.
Although we will try our best to make a quilt for your child, not all children will be accepted. If you wish to be given a reason your child was not accepted for a Love Quilt please send an email to Cyberfogie@aol.com and we will do our best to explain.
Below is the form you will need to fill out to be considered for a quilt. Here are some of the basic rules for a child to receive a quilt from Love Quilts.
1. AGE LIMITS 2-18: do not apply if your child is under 2 or over 18
2. Child must live in the United States.
3. Child must be under treatment for a physical illness or condition which is or was life threatening. If treatment for the condition is finished, a child can still qualify if there are ongoing serious effects either from the condition or from the treatment.
4. Child must have an online active webpage (such as caringbridge.org) with regular updates on the child's condition. A parent's Facebook may be used if it gives regular input on the child.
If you feel your child meets these guidelines please feel free to fill out the form. You will receive an email to notify you if your form was accepted. Thanks!
Has your child received a quilt in the past from another group online or locally? (this does not include virtual "quilts" posted only online)
Religion (optional):
If you have answered Yes to the question above, please explain what kind of a quilt it was and when it was received. If you could include a picture of it that would help as well.
Please note! By hitting the submit button you are giving your electronic signature agreeing to have your child featured to receive a quilt from Love Quilts. If you have any questions please feel free to email us atCyberfogie@aol.com. Thank you!
