Starlight Family Application

Starlight Children’s Foundation invites you to join our Starlight Family! In addition to our menu of programs available to our partner facilities around the world, Starlight offers Starlight Escapes in select cities. Starlight Escapes are special outings and events for chronically ill or injured children up to age 18, and their families. Additionally, teens and young adults ages 13-20 are eligible to join Starbright World, a monitored global online community offering support and connection through live chat rooms, blogs and shared photo albums. We embrace the technology that connects our Starlight families with opportunities. We send electronic alerts to members for local, donor-sponsored events as soon as they become available.

Starlight is committed to protecting the privacy of our families, volunteers, donors, and employees. All personal information collected is used to deliver services and information to those participating in our programs. This data remains confidential, and will never be sold or disclosed to third parties.

Child 1
Date of Birth *
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed *
E.g., Apr 23 2014
Date of Last Treatment *
E.g., Apr 23 2014
To prevent automated spam submissions leave this field empty.
Child 2
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 3
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 4
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 5
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 6
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 7
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 8
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 9
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 10
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 11
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Child 12
Date of Birth
E.g., Apr 23 2014
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Date Diagnosed
E.g., Apr 23 2014
Date of Last Treatment
E.g., Apr 23 2014
Parent/Guardian 1
Parent/Guardian 2
Parent/Guardian 3
Parent/Guardian 4
Parent/Guardian 5
Parent/Guardian 6
Household Information
Address
Files must be less than 8 MB.
Allowed file types: png gif jpg jpeg.
Referred By