Apply as a Family

Team IMPACT provides children with serious illness and disability the opportunity to experience positive social-emotional development through the support of a team.

Complete this form and a member of our staff will reach out to you to schedule an introductory call and complete the application process.

Child

First Name *

Last Name *

Age *

Diagnosis *

Diagnosis Details Maximum
255 characters

Parent/Guardian

First Name *

Last Name *

Phone *

Email *

Preferred Language *

Parent/Guardian #2

Do you want to include someone else?

First Name *

Last Name *

Phone *

Email *

Preferred Language *

Home Address

Street Address *

City *

State *

Zip Code *

Family Details

Family Race / Ethnicity

American Indian or Alaskan NativeAsianBlack or African AmericanLatinoNative Hawaiian or other Pacific IslanderWhiteOther

Household Income *

How Did You Hear About Us *

Social/News *

Other Social/News *

Other *

Additional Comments

Note:
Your answers to questions related to race/ethnicity and family income will not be shared with anyone and will have no bearing on your eligibility or participation in Team IMPACT. We collect this information in order to better analyze our program as a whole and to ensure we’re delivering a high-quality experience for families of every background, identity and income level.
If you do not receive a confirmation email immediately after submission please check your spam folder or send an email to [email protected]

Who We Work With

The Kids

Helping kids experience life beyond serious illness and disability.

Eligibility Requirements:

Children ages 5-16
Diagnosed with a serious or chronic illness
Require ongoing treatment and/or extended hospital stays
Could benefit, both socially and psychologically, from the support of a team
More than 1/3 have been diagnosed with cancer; other common diagnoses include cystic fibrosis, cerebral palsy and muscular dystrophy

Learn more about applying as a family

Aplicación en Español