Request A Smile Name * First Name Last Name Email * Phone (###) ### #### Your Relationship to the Child Parent/Guardian Hospital/Medical Staff Family Member Friend Other Child's Name * First Name Last Name Child’s Age Recipients must be in the elementary school age range (typically 5–11 years old). Child’s Diagnosis This helps us understand the child’s experience and tailor the care package appropriately. Hospital or Treatment Center (if applicable) Is there anything special we should know about the child’s interests or favorite things? * We do our best to personalize each package — favorite colors, characters, or hobbies are helpful! Would you like to share a photo or message for our Gratitude Page (optional)? Yes (we’ll follow up by email) No, thank you How did you hear about Little Smiles? Thank you! Our team will be in touch soon. Please note that submission does not guarantee a package, but we do our very best to honor all requests based on resources and timing.
