Pediatric Care Program

The Foundation provides one-time emergency funding to families who have a child receiving pediatric hospice care services, and are unable to pay for critical unfunded expenses. 

- Pediatric Relief Fund Request

- Small Gift Request

- Fingerprint Charms

- Photography Session

- Holiday Gift Program (October - December)


** Applications must be submitted by a member of the patient's hospice or palliative Care Team
** Note: We do not provide reimbursement for payments already made or items previously purchased.

Before completing one of the following gift request forms please read the guidelines below by clicking the purple button.
If you have access to Docusign, it may be used to obtain the required signatures. However, the instructions below MUST be followed! You can find the instructions by clicking the purple box titled "Docusign Instructions."

Pediatric Relief Fund Request
(Up to $500)

Please follow the steps below to submit a Pediatric Relief Fund Request.

1. Please download and complete the request form below by clicking the purple button. 

2. Some companies may be required to complete a W9 form in order to receive payment for services 

3. Once all the required information is obtained. Please submit the form by emailing it in pdf form to info@hpcfoundation.org

4. Please let us know your thoughts!

Small Gift Request 
(Up to $100)

Please follow the steps below to submit a Small Gift Request.

1. Please download and complete the form below by clicking the purple button.

2. Once all the required information is obtained. Please submit the form by emailing it in pdf form to info@hpcfoundation.org

3. Please let us know your thoughts!

Fingerprint Charm
Request

Please follow the steps below to submit a Charm Request.

1. Please download and complete the form below by clicking the purple button. 

2.  Once all the required information is obtained. Please submit the form by emailing it in pdf form to info@hpcfoundation.org

3. Please let us know your thoughts!

Photography
Request

Please follow the steps below to submit a Photography Request.

1. The Patient and their Photographer of Choice must complete the following form. After the form is completed, the Hospice Care Worker must sign before it is submitted.

** There are additional forms the photographer needs to fill out below!

2.  Once all the required information is obtained. Please submit the form by emailing it in pdf form to info@hpcfoundation.org

3. Please let us know your thoughts!

The Photographer MUST complete the following forms:

1. Photography Program Package Voucher Payment Form

2. Direct Deposit Agreement for Photographer

BONUS: Photography Session Tips for the Photographer

Holiday Gift Request
(October - December)

Please follow the steps below to submit a Holiday Gift Request (October - December ONLY)

1. Please download and complete the form below by clicking the purple button. 

Holiday Gift Request (Oct - Dec)

2.  Once all the required information is obtained. Please submit the form by emailing it in pdf form to info@hpcfoundation.org

3. Please let us know your thoughts!