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Request A Free Song (office request)
sol23
2024-02-16T01:31:42+00:00
“Song of Love” Office Request Form
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Child Info
(All fields with an * are required and must be filled in. Please make sure form is completely filled out before submitting it.)
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Child's Full Name
*
Age
*
- select -
1 month
2 months
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11 months
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16 years
17 years
18 years
19 years
20 years
21 years
Gender
*
- select -
Male
Female
Pronoun
If child identifies differently, please specify below
Child's Diagnosis (To Determine Eligibility Only)
*
Please include name of Affiliated Hospital / Health Facility / Hospice / Clinic or any other facility
*
Check box if you'd like to provide additional medical facility information
Medical Info
Medical Facility
City
State
- select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
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Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other/International
Phone (incl. area code)
If other/international country, please add complete address below
Special Interests, Hobbies, Favorite Things
*
Other (Family Members, Friends, Pets, Heroes, Foods, Movies, Favorite Places, Favorite Color, Etc.)
*
We will do our best to include all the names given but please limit the amount of the names. If too many are submitted we might not be able to get them all in.
What inspires / motivates your child the most?
What makes your child the happiest?
Style of Music (Please check at least 3 of your child's favorite kinds of music)
*
Uplifting Children's music
Pop
Dance
Rap/Hip-Hop
R&B
Rock
Country
Soft & Soothing
Any style
Please Use This Space To Spell Names Phonetically For Proper Pronunciation
Contact Name
Contact Title
Email
Parent or Guardian Info
Name
*
Address
*
City
*
State
*
- select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other/International
Zip/Postal Code
*
If other/international country, please add complete address below
Phone (incl. area code)
*
Email
*
Check box if song should be sent to an address different than the one above
Where Should Song Be Sent
Name
Address
City
State
- select -
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Other/International
Zip/Postal Code
If other/international country, please add complete address below
How Did You Hear Of Songs of Love?
Please choose one:
*
Give Kids The World
Facebook
Instagram
GKTW
Momcology
Hospital
Friend/Relative
Website Search
Magazine/Newspaper
Other
If other please specify
Publicity Release
I, the undersigned, hereby grant to Songs of Love Foundaton (Songs of Love) the right, license, and privilege to use my name, likeness, photograph, voice, and biography, as well as the "Song of Love" written for the above-named child in such a manner as Songs of Love shall deem appropriate, (including but not limited to fundraising, etc) in order to promote, advertise, and publicize Songs of Love and its charitable activities.
Allow for publicity
*
- select -
Yes
No
Digital Signature
Date
*
Upload Photo
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If possible, PLEASE upload a photo of child. (max file size:10mb)
Message
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