Beads at Home Application Form

Please enter your information below to be added to the Beads at Home Waiting List.

Thank you for your interest our Beads at Home Program (formerly Beads in the Mail). We are honored to support children and their families who do not have the opportunity to receive Beads of Courage® at their current hospital or clinic.

We currently have tremendous interest in the Beads at Home Program and, unfortunately, there is a waiting list. By filling out this form, you will be added to the waiting list and we will follow up with you by email.

There is an option to have someone sponsor a child who is on the waiting list for Beads at Home through our Beads at Home Sponsorship Program. This eliminates the need to be on the waiting list for so long. If you are interested in learning more, visit: https://beadsofcourage.networkforgood.com/projects/120974-beads-at-home.
Parent/Guardian Name Parent/Guardian Name First Last
Child's Name Child's Name First Last
Enrollment Age Requirements for the Beads of Courage Program - 21 years and under.

We ask that any adults who are coping with a condition contact our Beads at Home Manager at alapointe@beadsofcourage.org for information on the Bead for Bead Program.
Child's Date of Birth Child's Date of Birth / MM / DD YYYY
Contact Information
Email

Confirm Email Address
PLEASE ENTER EITHER A US OR INTERNATIONAL PHONE NUMBER:
Phone number (US format) Phone number (US format) - ### - ### ####

If international, please enter 111-111-1111 and enter your number in the International Phone Field
Phone number (International)
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
BOC Program Information

Please select the one program most appropriate to your condition.
Beads of Courage Program

Beads of Courage Program Hematology/Oncology Cardiac NICU Burn Chronic Condition/Rehab/Pediatric ICU/Trauma Recovery
Tell us about yourself and your interest in the BOC Program
At which Hospital/Organization does your child receive treatment?
(Please provide the FULL hospital name)
Name of Primary Doctor/Specialist Name of Primary Doctor/Specialist First Last
How did you hear about Beads of Courage?

How did you hear about Beads of Courage? Social Media Friend/Family News Parent Support Group Other Other
Comments:
Tip: Please consider adding alapointe@beadsofcourage.org to your email contact list to ensure that you receive emails regarding the waiting list and enrollment from Ashley Lapointe, our Beads at Home Program Manager.

Unfortunately, some of our emails end up in people's spam folder and they do not receive important waiting list and enrollment information.
Spam Protection. Please answer this simple question:
In the number 77283, what is the 4th digit?

Beads at Home Application Form

Beads at Home Application Form

Enrollment Age Requirements for the Beads of Courage Program - 21 years and under.

Contact Information

PLEASE ENTER EITHER A US OR INTERNATIONAL PHONE NUMBER:

BOC Program Information