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Please choose the location nearest the child's home: *Mason City, IAFort Collins, COWatertown, SDEligible homes are within 30 miles of Mason City, Iowa, Des Moines, Iowa, Fort Collins, Colorado, and 35 miles of Watertown, South Dakota

Child's First Name *

Child's Last Name *

Child's Date of Birth *

Child's Age *

Male or Female *MaleFemale

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

Father's First Name *

Father's Last Name *

Father's Phone

Mother's First Name *

Mother's Last Name *

Mother's Phone

Main Contact Phone Number *

Email Address *

Does the child live at this address permanently? *YesNo

If no, does the child reside where the bedroom makeover would take place at least 50% of the time? *YesNo

Are you the owner of the property listed on this application? *YesNoIf NO, MHP must have landlords contact info. in order to get permission to redecorate.

Please list the siblings and their ages also living at the address

Does the child named on this applicant have a bedroom of his/her own? *YesNo

Does the child named on this applicant share a bedroom with a sibling? *Yes No

If yes, list name and age:

State child's documented diagnosis: *

Is this a chronic or terminal illness? *ChronicTerminal

Please give details of the kind of treatment the child is receiving currently: *

As a parent, what are your desires for the room? *

What are the child's favorite colors, characters, theme, etc? *

What benefit are you hoping the child will gain from having a bedroom makeover? *

IMPORTANT: Publicity is vital to the growth of our organization. It is through publicity that we gain potential donors as well as applicants. The family will be asked to sign a MEDIA CONSENT form if chosen for a bedroom makeover. *I understand

IMPORTANT: You may be asked to submit a Healthcare Professional Form, verifying your child's diagnosis. While we know this can hold up an application, we must have one on file before any work is done on the room (if this form is required by the MHP Affiliate). You may submit the actual application asap, but if application is accepted, this form must be completed by the child's healthcare team before any work is done on the room. You may print off this form to take to your child's healthcare provider to have them sign and mailing it to the MHP Affiliate's address or direct the healthcare provider to: http://myhappyplacemc.com/healthcare-professional-form/

Name of the person Filling out this application *

Relationship to nominee:

Phone number of the person filling out this application *

I confirm that all of the above information is true and correct by submitting this application.Confirm