Refer A Child

Know a Child Who Could Use Our Support?
If you’d like to refer a child facing cancer or another serious pediatric illness, please complete the form below. A member of our team will be in touch as soon as possible.

Thank you for helping us bring comfort, care, and hope to families who need it most.

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.

Important Application Information - Once we receive a referral, we will forward the application for completion.

To avoid delays, please ensure that all applications submitted via email are fully completed and signed. Incomplete or unsigned applications will not be processed. If you are requesting assistance for a specific bill, a copy of the corresponding invoice must be included. Applications without proper documentation will be denied.

Please note:

The Team Jack Foundation currently provides assistance only to patients residing in New Jersey.
To allow for year-end processing, applications submitted in December will not be reviewed until January.
Please allow up to 4 weeks for application review and the distribution of gifts.

As a small foundation, we do our best to support as many children as possible. To help us help you, please include a doctor’s note confirming the diagnosis and that the patient is currently in active treatment.

What We Can Help With

The Team Jack Foundation may be able to assist with a variety of needs, including—but not limited to—medical expenses, household bills, and gift cards for essentials like food and gas. Please note that we do not cover taxes, loan payments, credit card bills, or provide direct cash payments to applicants. We also encourage you to consider what might bring your child joy—even if just for a day. Sometimes a simple smile can mean everything.

Thank you for your understanding and for helping us honor Jack’s legacy by supporting families in need.

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