Tote Bag Signup

Get a KidsCan Tote Bag!

Patient Tote Bags:
KidsCan delivers a tote bag containing age and gender-appropriate gifts and a gift card. The bags also contain resources, supplies and items to help make hospital stays easier.

KidsCan welcomes referrals.

Eligibility:

  • Child is age 0 to 18 years old on date of diagnosis
  • Child within 6 months of pediatric cancer diagnosis date
  • Currently in treatment for pediatric cancer
  • Child is receiving primary treatment in Minnesota
  • One tote bag per child/family

Please fill out the form below and KidsCan will send you a tote bag after verification. If you have already signed up but want to edit your information, contact KidsCan.

Policy:  KidsCan reserves the right to make the final determination regarding eligibility for a particular child/family, and reserves the right to change eligibility requirements.

Child With Cancer
*Items marked with an asterisk are required.

*Child's First Name:
*Child's Last Name:

Needed for age and gender-specific tote bag items:
*Birth Date: e.g. MM/DD/YYYY
*Gender: Male Female 

*Cancer Diagnosis:
*Date of Diagnosis: e.g. MM/DD/YYYY
*Child's Primary Oncologist:
*Child's Hospital:
Child's Social Worker:

CaringBridge page, CarePage, or blog address (if applicable):

Number of siblings with whom this child lives:

*Street Address:
*City:
*State: *Zip:

Family Information - Parents/Caregiver

First Parent/Caregiver

*Last Name:
*First Name:
Title: (Mr., Mrs., Dr., etc. if desired)

*Email Address:
*Confirm Email Address:

*Relationship to Child with Cancer:
Comments if Other:

*Primary Phone:
Alternate Phone:

 Use the same address as the child with cancer?
*Street Address:
*City:
*State: *Zip:

*Who referred you to KidsCan (How did you hear about us)?

Comments if Other

General Comments (optional):

Second Parent/Caregiver

Last Name:
First Name:
Title: (Mr., Mrs., Dr., etc. if desired)

Email Address:
Confirm Email Address:

Relationship to Child with Cancer:
Comments if Other:

Primary Phone:
Alternate Phone:

 Use the same address as the child with cancer?
Street Address:
City:
State: Zip:

YES, I/We have a child age 0-18 years with cancer primarily receiving treatment in Minnesota and I/we agree to give KidsCan permission to contact my child's physician(s) and/or social worker for confirmation of the qualifying criteria. I hereby authorize the release of this information to KidsCan of Minnesota.