Refer A Child

If you would like to refer a child facing a cancer or other pediatric illness, please complete the form below. We will respond as soon as possible. Thank you.

Please complete the form below

Name

First Name

Last Name

Child's Name

First Name

Last Name

Cell Number

(###)

###

####

Email Address

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

You may use this space to provide us with a brief description.

If you have any specific requests or questions you may use this space for any additional information you would like to provide.

Please make sure the application provided through email is complete and signed or it may delay your request. If you are requesting assistance for a specific bill, then the invoice must be included or the application will be denied. At this time, The Team Jack Foundation only assists patients residing in NJ. To allow for year-end processing, no applications that are submitted in December will be accepted until the following January. Please allow up to 4 weeks for processing and payment of all gifts. We are a small foundation and will try to help as many children as possible. Please include a doctor’s note stating the diagnosis and confirming that the patient is in active treatment at the present time.

The Team Jack Foundation may help with the following, but not limited to medical expenses, home bills, food & gas gift cards, etc, but we do not pay taxes, credit cards or give money directly to the applicant. We would ask you to consider what your child may want that could bring a smile, even for a day.

We will email it to you as soon as we receive your name and email. Thank you.

Please mail it to: The Team Jack Foundation PO Box 582 Lincroft, NJ 07738