Hopecam Application – Connecting Homebound Children with Cancer and School

To find out if your child qualifies for the Hopecam program, fill out the online application below and we’ll contact you. (All fields are required).

Parents’ First Name:
Parents’ Last Name:
Address:
City:
State:		Zip:
Phone:
Email:
Do you have a Hi-speed connection at home?	yes	no
Best time to contact you:

Child's Name:
Illness:
Place of Treatment:
Diagnosed Date:
Treatment Start Date:
Expected Homebound Time:
School:
School Principal:
School Phone:
School Address:

Comments:

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