Adopt A Family Program – Tender Hearts Inc.

Adopt – A – Family

This is traditionally a Holiday program but we run the program year long. We offer assistance with families who have a medically fragile child, or children. We provide assistance in the form of food and new items from clothing to household items.

The relief and happiness this program provides is not quantifiable. A study done by the Harvard Public School of Health shows that “toxic stress has harmful effects on the brain and other organ systems”. The study further went on to show that things such as hopefulness, optimism, and being surrounded by a supportive network of positive family and friends also greatly contributed to increased health. (http://www.hsph.harvard.edu/news/magazine/happiness-stress-heart-disease/).

All our programs are aimed to provide happiness and relief from stress even if just for a short period of time.

Tahiri

Jhalil

Nicole, Jaden, Jeremiah, Ariana, Isis and Gabriella

Helping One Family At A Time

Adopt A Family Assistance Form

We provide gifts for each child in the family. All applicants must list a medical professional and or a social worker that can confirm the child’s medical condition. The child must be a DE Resident, provide photo release form and medical condition of child. No other documents are required for this program.

You will be notified if your application is accepted and additional information will be provided at that time.

Your Name*
First Last
Phone*
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Referral's Information
Hidden
Referral’s Information*
Referral’s Name*
Referral’s Phone Number*
Referral’s Email*
How were you referred to Tender Hearts?*
Have you used this program before for this child?*
Child w/ Medical Condition: A statement of diagnoses including the medical professionals contact information for compliance purposes. No application will be provided without this information.
Name of Child w/ Medical Condition
First Last
Gender*
Age*
Medical Condition of Child*
Please provide a brief explanation of the qualified physical medical condition.
Requests*
Would you like to make a request for additional family members?*
- Yes
- No
Additional Family Member Requests
* Provide 3 items from their wish list each
* Sizes if applicable for shoes and clothing
* Age of each child with name on each list
* We deliver the gifts.
* Note: All siblings must be 18 years of age and younger.
Name*
First Last
Gender*
Age*
Requests*
Name
First Last
Gender
Age
Requests
Name
First Last
Gender
Age
Requests
Name
First Last
Gender
Age
Requests
I represent and warrant that I have read, understand, and agree with the foregoing, and in acknowledge sign my name below.
Signature*
Printed Name*
First Last
Relationship to Children*
Photography Release
I hereby authorize Tender Hearts, Inc. (the “Company”), to publish photographs of myself and/or the minor child or children listed below, and our names and likenesses, for use in the Company’s print, online and video-based materials, as well as other Company publications.

I hereby release and hold harmless the Company from any reasonable expectation of privacy or confidentiality for myself and for the minor child or children listed below associated with the images specified above.

I further acknowledge that participation is voluntary and that neither I, the minor child or children, will receive financial compensation of any type associated with the taking or publication of these photographs or participation in company materials. I acknowledge and agree that publication of said photographs confers no rights of ownership or royalties whatsoever.

I hereby release the Company, its contractors, employees and any third parties involved in the creation or publication of the Company publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor/child children listed below.

I am the parent or legal guardian of the child or children listed below and that I have full authority to consent and authorize the Company to use their likenesses and names.

Adopt – A – Family

Tahiri

Jhalil

Nicole, Jaden, Jeremiah, Ariana, Isis and Gabriella

Helping One Family At A Time

Adopt A Family Assistance Form

Referral's Information

Child w/ Medical Condition: A statement of diagnoses including the medical professionals contact information for compliance purposes. No application will be provided without this information.

Additional Family Member Requests

Photography Release

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