The Good Box Application

for Parents and Caregivers

One Mission’s Good Box Care Packages provide self-care items to parents of children with pediatric cancer reminding them to take care of themselves.

*Parent(s) must have a child aged 18 or under 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*
Best Mailing Address for Parent(s)/Guardian(s) (MUST BE AN ADDRESS THAT CAN ACCEPT LARGE PACKAGES)*
Is Patient Currently in Treatment for Pediatric Cancer? PATIENT MUST BE IN TREATMENT (AND CONFIRMED BY MEDICAL PROFESSIONAL) FOR APPLICATION TO BE CONSIDERED.*
Name of Medical Professional Who Can Confirm Diagnosis*
Patient's Name (Child of Good Box Recipient)*
MM slash DD slash YYYY
Please Select the Item(s) You Think the Parent(s)/Guardian(s) Would Be Most Interested In:
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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