Alex's Care Kit - Alex's Team

Alex’s Team is accepting nominations to ship Alex’s Care Kits to children currently receiving cancer treatment!

Your Name*

First

Last

Would you like your nomination to remain annonymous?*

Yes

Your Email address*

Relationship to Nominee*

Nominee's Name*

First

Last

Nominee's Parent/Guardian Name*

First

Last

Parent/Guardian Email*

Nominee's Age*

Nominee's Gender*

Nominee's Mailing Address*

Street

City*

State

Zip Code*

Which Hospital Is Currently Treating The Nominee?*

Nominee's T-Shirt Size*

Anything Else You Would Like to Add?

Are you human?*

This field should be left blank