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

• Aged 0-21 years old
• Resident of Texas
• Located in the Houston area and surrounding counties
• Diagnosed and in a doctor’s care for one of the below brain/spine tumors

Patient First Name *

First

Patient Last Name *

Last

Patient Age *

Parent Name *

Physical Address *

City *

State * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

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 & Recurrent Medulloblastoma

Recurrent Pineoblastoma

New & Recurrent PNET of the brainstem or spinal cord sPNET

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

New and Recurrent Ependymoma

Recurrent Primitive Neuroectodermal Tumors (PNET)

Recurrent Supratentorial PNET (sPNET)

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

Δ