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Cheer Package Request Form
We currently ONLY ship to the United States and Canada.
Requestor Name
*
Requester Email
*
Patient Name
*
Patient Address
*
Patient City
*
Patient State
*
Select
United States - Alabama
United States - Alaska
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Canada - Northwest Territories
Canada - Nova Scotia
Canada - Nunavut
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Canada - Saskatchewan
Canada - Yukon
Patient Zip Code/Postal Code
*
Hospital Name
*
Hospital Address
*
Hospital Room Number
Hospital City
Hospital State
Select
United States - Alabama
United States - Alaska
United States - Arizona
United States - Arkansas
United States - California
United States - Colorado
United States - Connecticut
United States - Delaware
United States - Florida
United States - Georgia
United States - Hawaii
United States - Idaho
United States - Illinois
United States - Indiana
United States - Iowa
United States - Kansas
United States - Kentucky
United States - Louisiana
United States - Maine
United States - Maryland
United States - Massachusetts
United States - Michigan
United States - Minnesota
United States - Mississippi
United States - Missouri
United States - Montana
United States - Nebraska
United States - Nevada
United States - New Hampshire
United States - New Jersey
United States - New Mexico
United States - New York
United States - North Carolina
United States - North Dakota
United States - Ohio
United States - Oklahoma
United States - Oregon
United States - Pennsylvania
United States - Rhode Island
United States - South Carolina
United States - South Dakota
United States - Tennessee
United States - Texas
United States - Utah
United States - Vermont
United States - Virginia
United States - Washington
United States - West Virginia
United States - Wisconsin
United States - Wyoming
Canada - Alberta
Canada - British Columbia
Canada - Manitoba
Canada - New Brunswick
Canada - Newfoundland and Labrador
Canada - Northwest Territories
Canada - Nova Scotia
Canada - Nunavut
Canada - Ontario
Canada - Prince Edward Island
Canada - Quebec
Canada - Saskatchewan
Canada - Yukon
Hospital Zip Code/Postal Code
Admission Date
*
Estimated Hospital Discharge Date
Holidays the Patient Celebrates
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New Years
Valentines Day
Easter
Independence Day
Halloween
Thanksgiving Day
Hanukkah
Christmas
Patient Intrest
Patient Age Range
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0-2
3-5
6-9
10-12
13-15
16-19
20-29
30-39
40-49
50+
Patient Gender - This is used to tweek the contents of the package to Male, Female, or Gender Neutral
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Neutral
Please enter the text from image below in the field below.
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Menu
About Us
Founder's Message
Home
Request Cheer Package
Articles
Ask Smile E.
PCD Awareness
Name Submission for 2022 Shirt
PCD Artist Project
2020 PCD Artist Project
2021 PCD Artist Project
2022 PCD Artist Project
Sometimes PCD is ...
Turtle On 100 Challenge
Daily Journal Prompt
October Awareness Post
PCD Resource List
Physiotherapy
Random Fact Friday
Recipe Share Wednesday
Topic Thursday
Trivia
Tuesday Trivia
October Trivia
Support PCD Smiles
PCD Style Shop
Donations
Giving Saturday
Donation Spotlight
Turtle Talk
Search