All sections must be completed to receive full consideration. Parent/Legal Guardian must fill out this form. 

Parent/ Legal Guardian's Name *
Parent/ Legal Guardian's Name
Parent/ Legal Guardian's 2 Name
Parent/ Legal Guardian's 2 Name
Child's Full Name *
Child's Full Name
Medical Considerations *
Current Address (if different from referral form)
Current Address (if different from referral form)
Are the parents owners of the residing residence and location in which the child would be receiving a Rooms to Thrive™? *
Survey *
Survey
We currently live a sustainable and green lifestyle.
It's important that my family lives in a toxic free environment.
I am always looking for new ways to improve our clean living lifestyle.
I believe in balance.
We eat organic foods.
We use essential oils.
We exercise daily.
We love listening to loud music often.
We have a TV in my child's bedroom.
My child eats in his/her room.
My child reads in his/her room.
Does the family want a television in the R2T recipients room? *
Does the R2T child reside with both biological parents? *
Has the child ever had a wish granted or been considered by any wish granting organization? *
Has the family applied for, been considered for or received a room renovation from any other organizations? *
Are there any concerns or issues with fundraising (up to 30% of the estimated cost of renovation) and/or asking friends and family to collaborate? *
Are you willing to provide CNF lead designer with a key to your home? *
Facebook
Instagram:
YouTube:
Pinterest
(Child's Name)
Current Bed Size *
This will be a place for me to be: *
(select all that apply)
Please list full names of each member, relationship to R2T child, age/date of birth and if this member shares a room with the child.
Family Member 1
Family Member 2
Family Member 3
Family Member 4
Family Member 5
SCHEDULING ROOM INSTALL please indicate three possible date(s) for the fulfillment of a Rooms to Thrive™ install. *
SCHEDULING ROOM INSTALL please indicate three possible date(s) for the fulfillment of a Rooms to Thrive™ install.
(Note: preferred dates cannot be guaranteed)
*
Please list any conflicting dates that might impact your ability, positively or negatively, to participate in receiving a Rooms to Thrive™. (e.g., upcoming treatment, vacation, school, work, etc.)
CHILD RACE/ETHNICITY
The following information if OPTIONAL and will be used for STATISTICAL PURPOSES ONLY. The response should be provided by the child or his or her parent(s)/guardian(s) if they choose to do so. Please select one or more of the choices as appropriate.
I understand and agree: That no promises or assurances whatsoever have been made to me by any representative of the Carsyn Neille Foundation regarding the requested Rooms to Thrive™; 
 That the granting of any Room and the participation of any person in the process is contingent upon approval by the Carsyn Neille Foundation and the child’s physician, as well as full compliance with all conditions, qualifications, and restrictions designated by the Carsyn Neille Foundation; 
 That all individuals with parental or custodial rights for the child must approve the install before it is granted and must sign all necessary documents; and 
 That the receipt of a wish may impact the eligibility for public assistance and/or benefits. 
 I promise that the information provided by me is true and complete to the best of my knowledge.