Lurie’s Children’s Hospital patients who qualify for a Kiss of HOPE^® will be automatically referred to our program by a Lurie’s Brain Tumor program social worker.  However, if your child meets the following requirements and is seen at another hospital, please fill out the form below.

• Aged 0-18 years old
• Resident of Texas
• Located in the Houston area and surrounding counties
• Diagnosed and in active treatment for one of the below brain/spine tumors

Patient First Name *

First

Patient Last Name *

Last

Patient Age *

Parent Name *

Physical Address *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip *

Home Number

Mobile Number *

Email *

In order to qualify for a Kiss of HOPE, CKMC currently accepts the following diagnoses. Please select your child’s diagnosis below: *

Brainstem Gliomas

Glioblastoma Multiforme

Anaplastic Astrocytoma

New and Recurrent Medulloblastoma

Recurrent Pineoblastoma

New and Recurrent PNET or sPNET

New & Recurrent Atypical Teratoid Rhabdoid Tumor (AT/RT)

New and Recurrent Ependymoma

Diagnosis will be confirmed by the patient’s attending physician. Please provide the following:

Physician Name *

Hospital Name *

Hospital City *

Physician Phone Number *

Physician Fax Number