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Legacy Retreat® Interest Form

Please submit this form if your family or a family you know could potentially benefit from the services of Inheritance of Hope. THIS FORM DOES NOT INCUR ANY OBLIGATION OR COMMITMENT. This is simply a way that you can make us aware of families to contact about our offerings. Inheritance of Hope serves families with children 18 and under AND a parent diagnosed with a life-threatening illness. Our services to these families include literature, scholarships, and all-expenses-paid Legacy Retreats®. Please submit an interest form only for qualifying families.
SECTION ONE -- FAMILY INFORMATION
Diagnosed Parent First Name*
Please enter your first name.

Diagnosed Parent Last Name*
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Diagnosis*
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Age*
Please enter your age in numeric format (e.g., 45)

Gender*
Invalid Input

Address Line 1
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Address Line 2
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City
Please enter your city.

State
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ZIP Code
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Email Address
Please let us know your email address.

Primary Phone Number
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Spouse (or Caregiver) Name
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SECTION TWO -- CHIDREN IN THE FAMILY
First Child Name*
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Age*
Please enter your age in numeric format (e.g., 45)

Gender*
Invalid Input

Second Child Name
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Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Third Child Name
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Fourth Child Name
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Fifth Child Name
Invalid Input

Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

Sixth Child Name
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Age
Please enter your age in numeric format (e.g., 45)

Gender
Invalid Input

SECTION THREE -- REFERRAL INFORMATION
Your First Name*
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Your Last Name*
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Your Relationship to Diagnosed Parent*
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Primary Phone Number*
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Email Address*
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How did you hear about Inheritance of Hope?*
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Comments
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