Request a Bracelet!
Hello! You can fill out this form if you want to request a bracelet, for yourself or for another brave hero. www.tiedtogetherbracelets.weebly.com
Child's first name
*
Child's last name
*
Child's gender
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Boy
Girl
Child's day, month and year of birth
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Child's day of birth
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Child's month of birth
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January
February
March
April
May
June
July
August
September
October
November
December
Child's year of birth
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1996
1997
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2001
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2005
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2009
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2011
2012
2013
2014
2015
2016
2017
2018
Photo of the child
Bestand Uploaden
NOTE: Sometimes the form does not work when uploading a picture. I'd love to see who I make a bracelet for, so if you're unable to upload a picture please email one instead :)
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of
Child's life changing disease, disorder or disability
*
Please describe the current status of the child and what he/she is going through
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Is it an emergency? (e.g., if the child is on hospice)
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No
Yes
Please estimate if the child has a small, regular or big wrist size for his/her age
*
Please describe what to be on the bracelet for the child, and mention a colour for every part (incl. background)
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Child's favourite things and favourite colours
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Child's address to send the bracelet to
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State/province child lives in
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Child's hospital
Child's Facebook page, site, blog, Instagram, ...
Your name
*
Your relationship to the child
*
Your email address
*
How did you find out about me? :)
Further comments
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