LANTERN Interest Form

LANTERN supports families of children with serious, life-limiting illnesses, complex medical conditions and other disabilities. Share a little about your family and a member of the PPCC team will be in touch soon. All fields are required unless marked optional.

Contact information

First name

Last name

Email

Phone

Street address

City

State

ZIP

Relationship to child

Parent

Grandparent

Legal guardian

Other family or caregiver

Tell us about your child's medical conditions (optional)

Care facility or hospital (optional)

What support would be helpful?

Basic Needs & Daily Living

Education, Development & Vocational Support

Home, Community-Based Care & Care Coordination

Palliative Care, Hospice, Grief & Bereavement Support

Finances, Benefits & Employment

Medical & Healthcare Services

Medical Equipment, Technology & Accessibility

Mental Health, Psychosocial & Spiritual Support

Legal, Advocacy & Family Services

Recreation & Community Support

Not sure yet

Other (please elaborate)

How did you hear about LANTERN?

Anything else you'd like us to know? (optional)

Only PPCC's LANTERN team sees what you share here. If you don't end up joining, we delete your submission within about a month. Privacy Policy