HUG Bag Request Form

THIS FORM IS FOR SOCIAL WORKERS ONLY, CONTACT YOUR SOCIAL WORKER FOR MORE INFORMATION

The Hug Bag program is a Patches of Light initiative that hopes to bring a bit of sunshine into a critically ill child’s life. Using items found on an interest form (which is located below, a hug bag is assembled and delivered to the hospital or to the child’s home. Items in the hug bag reflect the interests of the child and hopefully bring some respite from worry.

*Hug bag requests must come from the child’s social worker.

Social Worker Contact Information

Name

First Name

Last Name

Title

Agency or Hospital

Phone

Country

(###)

###

####

Where should the HUG Bag be delivered?

Patients Information Receiving the HUG Bag

Name

First Name

Last Name

Diagnosis

Is patient currenlty hospitalized?

Yes

Age

Patients Gender

Patients Cultural Background

(this will only be used to enhance the HUG bag by providing books, movies, magazines, etc. based on the patient's culture. This information is strictly voluntary).

Anything that should NOT be included in the HUG Bag:

(this may include scents, cultural aversions, games or toys the child would have difficulty with, etc.)

Favorite snack, restaurants, etc:

Favorite books, authors, magazines, etc:

Extras: Please feel free to list anything you think the child might enjoy.

Thank you! If you have any questions please do not hesitate to contact us.