Kyra's Hope Foundation

Submit support requests

Use the tabs below to submit a milestone wish or request family support. We respond within 3 business days.

Tell us about your child and family needs so we can coordinate comfort kits, caregiver care, or other practical support. We'll follow up within 3 business days.

Application submitted by *

Child's Name *

Child age *

Diagnosis *

Parent/Guardian Name(s) *

Home/Cell Phone Number *

Email *

How did you hear about this program?

Support Type *

Request details *

Shipping Address

Full shipping address *

Hospital/Medical Facility

Hospital Name *

City *

State *

Hospital Social Worker Name *

Hospital Social Worker Phone *

Hospital Social Worker Email *

By checking the following boxes I accept the following termsI understand that this is a gift to my child. The organization is not liable for harm caused by this gifts.I give permission to use a photo of my child to help promote this program. No last names or addresses will be disclosed.I give the organization permission to verify the above information with my child’s social worker listed above.

Parent/Guardian Signature *

Date *