A Kid Again provides hope, happiness, and healing to families raising a child with a life-threatening condition.
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Chapter Assignment
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Enrolled Child Information
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A Kid Again Serves Children up to the Age of 20
Please only list one diagnosis per text field.
Additional Diagnosis
Please only list one diagnosis per text field.
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Additional Diagnosis 2
Please only list one diagnosis per text field.
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Additional Diagnosis 3
Please only list one diagnosis per text field.
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Hospital Information
Social Worker/Medical Provider
By completing the below information, you are providing permission for A Kid Again to reach out to your social worker to request medical authorization. If we are unable to complete this request an A Kid Again representative will reach out for additional support.
Parent/Guardian Information
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Second Parent/Guardian
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Contact Information
Please add each sibling that lives in the household of the enrolled child.
Sibling Information
Please add information for each sibling that lives in the household of the enrolled child.
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Sibling 2
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Sibling 3
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Sibling 4
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Sibling 5
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Sibling 6
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Sibling 7
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Sibling 8
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Sibling 9
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Sibling 10
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Foster Parents
Please note: We must receive a copy of the legal documents if you have custody of someone else’s child(ren), or if you are a foster parent of a child prior to their participation in A Kid Again.
Acceptable file formats are jpg, png, or pdf