Home/Request a Brave Box

Request a Brave Box.

Checking request availability…

A thoughtful request process built around the child and family.

The Foundation reviews each request according to program eligibility, available inventory, funding, service area, and current capacity.

Choosing not to grant photo, video, story, or fundraising-link permission will not affect a child’s eligibility to request or receive a Brave Box.

Complete all fields unless marked optional or only required when applicable. For preferences or dislikes, enter “None” or “Not sure” when appropriate.

Child Information

Child’s First Name

Child’s Last Name

Child’s Exact Age

Age in Years or Months

Enter the child’s age, then choose years or months. For infants, use months.

Gender

Has this child already received a copy of the Brave Like Remington book?

Yes No Unsure

This helps avoid unnecessarily sending duplicate books.

Medical / Hospital Information

Is the child currently hospitalized?

Hospital / Treatment Facility — Required

Social Worker / Child Life Specialist Name — Required

Social Worker / Child Life Specialist Phone Number — Required

Social Worker / Child Life Specialist Organization Email — RequiredProvide the specialist’s email address issued by their hospital, treatment facility, or organization.

Complete and accurate care-team information is required. Applications that do not properly include the hospital or treatment facility, a social worker or child life specialist’s name and phone number, and that specialist’s organization-issued email address will automatically be denied.

General Reason for Request

Any allergies, sensitivities, restrictions, or other considerations?

If yes, please explain — Required when Yes is selected

Families will not be required to provide extensive private medical records simply to request a box.

Parent / Guardian Information

Parent / Guardian Name

Relationship to Child

Phone

Preferred Contact Method

Delivery & Referral

Delivery Method

How Did You Hear About Us?

Delivery Address

Enter the family’s mailing address or the participating hospital/organization’s complete delivery address.

Street Address (include apartment, unit, or room if applicable)

City

State / Province

ZIP / Postal Code

Photo, Story & Media Permission

These permissions are optional and do not affect whether a child is eligible to request or receive a Brave Box. Leave any optional permission unanswered if you do not wish to make a selection.

Photo & Video Permission

Yes, I give permission to Brave Like Remington Foundation to use photographs and/or videos that I voluntarily submit of my child, including photos or videos of my child receiving or opening their Brave Box, on the Foundation’s website, social media accounts, printed materials, fundraising materials, promotional materials, and other Foundation communications. No, I do not give permission to use my child’s photographs or videos publicly.

Child’s Story Permission

Yes, I give permission to Brave Like Remington Foundation to share my child’s first name, age, general diagnosis/illness information that I voluntarily provide, Brave Box experience, and story on the Foundation’s website, social media accounts, printed materials, fundraising materials, promotional materials, and other Foundation communications. No, I do not give permission to publicly share my child’s story.

Family Fundraiser/Support Link

Yes, I give permission to Brave Like Remington Foundation to share a fundraising or family-support link that I voluntarily provide when sharing my child’s story. No / Not applicable

Fundraising/support link — Required only if sharing a link

Important: Participation in any photo, video, story, or fundraising-link sharing is completely voluntary. Choosing “No” will not affect a child’s eligibility to request or receive a Brave Box.

Parent/Legal Guardian Authorization

I certify that I am the parent or legal guardian of the child named in this request, or that I otherwise have legal authority to provide the permissions selected above. I understand that information, photographs, or videos authorized for public use may be viewed, shared, or redistributed by others after publication and that Brave Like Remington Foundation cannot control third-party sharing after publication.

I certify that I am authorized to provide the permissions selected above.

Parent/Legal Guardian Full Name

Relationship to Child

Electronic Signature — Type your full legal name

Email Address

Date

Automatically recorded with the submission date and time.

Request Acknowledgment I understand that submitting a request does not guarantee receipt of a Brave Box. Fulfillment depends upon eligibility, inventory, available funding, service area, and Foundation capacity.