The Junior Good Box Application

for Patients

One Mission’s Junior Good Box Care Packages are filled with books, games, arts & crafts, and toys that bring fun, joy, and smiles to patients, right when they need it most.

*Patient(s) must be age 18 or under and currently in cancer treatment. Applications without sufficient information to confirm pediatric cancer diagnosis, or where diagnosis cannot be confirmed, will not be considered.

"*" indicates required fields

Name of Person Filling Out Application*
Name of Patient Junior Good Box Application is For*
Best Mailing Address for Patient (MUST BE A LOCATION THAT CAN ACCEPT LARGE PACKAGES)*
Is Patient Currently in Treatment for Pediatric Cancer? PATIENT MUST BE IN TREATMENT (AND CONFIRMED BY A MEDICAL PROFESSIONAL) FOR APPLICATION TO BE CONSIDERED.*
Name of Medical Professional Who Can Confirm Diagnosis*
Patient's Date of Birth*
Patient's Developmental Level (if different than age)
Patient's Gender*
Patient's Favorite Colors (please choose all that apply)*
Would You Be Willing to Let One Mission Share Your Quotes and/or Photos to Help Us Continue to Secure Funding for Future Families? (Quotes/photos may be used on social media, or in donor reports, marketing materials, etc.)*
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