Landon’s Light Miracle Moment

The Request – How it works:

Landon’s Light Foundation wants to be the light that brightens the path for others. The foundation shines bright and spreads kindness by granting a miracle moment valued up to $1,500 or financial assistance up to $750 for kids fighting a serious medical condition such as cancer. Landon’s Light Foundation anticipates providing a miracle moment for up to 12 children per year. Anyone can refer a child to Landon’s Light Foundation including medical professionals, parents or legal guardians. The referral form below must be filled out by a family member. The more detail you provide on your form, the faster we can process your application. Please include additional information that may be helpful about your child’s miracle moment. A miracle moment can take up to three (3) months to process depending on the request.

Examples of miracle moments may include: a family weekend getaway, sporting event experience, bedroom makeover, local shopping spree, iPad, gaming system – the list is endless!

Who is Eligible for a Miracle Moment or Financial Assistance?

A child:
- 18 years old or under, and
- Diagnosed with a chronic medical condition such as cancer, and either
  - Resides within 60 miles of the Fargo/Moorhead/West Fargo Community, or
  - Receives treatment at Roger Maris Cancer Center, Fargo, ND, Sanford Medical Center, Fargo, ND or Essentia Health, Fargo, ND.
If your child is receiving or has received support from another organization, this does not preclude you from being approved for a Miracle Moment.
- Landon’s Light Foundation is not deemed a wish granting organization.
For ﬁnancial assistance, you must submit a bill and Landon’s Light Foundation will pay it directly up to $750.
If your child has already received a miracle moment or financial assistance and has since relapsed, they are eligible to apply for another miracle moment or financial assistance within 12 months of the date of relapse.

When will I hear from Landon’s Light Foundation?

After we receive your submission, a Landon’s Light representative will be in touch within 10 business days to discuss your application. Once the miracle moment or financial assistance details have been agreed upon by you and Landon’s Light Foundation, a Landon’s Light volunteer will deliver the request, or it will be mailed to you directly.

*A miracle moment can take up to three (3) months to process depending on the request. Please include as much detail as possible on your application.

Our vision is to be the light and spread kindness. We look forward to providing a small piece of hope, compassion and comfort to your family during this time of hardship. We look forward to receiving your application!

Thank you,
Landon’s Light Foundation

Referral Form

Date *

Patient Name *

First

Last

Date of Birth *

Gender

Male
Female

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Cell Phone *

Home Phone

Email *

We only use your email address to contact you regarding your child's miracle moment.

Parent/Guardian Names *

Sibling(s) Names and Ages

Date of Diagnosis *

Date of Relapse (if applicable)

How Did You Hear About Us? *

Diagnosis *

Social Worker *

Physician *

Information Regarding Treatment *

What is the current status of your child's treatment?

Miracle Moment Requested (up to $1,500) *

PLEASE BE AS DETAILED AS POSSIBLE.

Additional Information Regarding Patient *

Is there anything else we should know before calling?

Upload Bill for Financial Assistance

Click or drag a file to this area to upload.

Landon's Light Foundation will pay your bill(s) directly, up to $500

We reserve the right to verify any information contained in any bill provided to us. By submitting this Referral Form, I acknowledge and agree that (1) Landon’s Light Foundation is not obligated to provide a Miracle Moment or Financial Assistance, as applicable; and (2) Landon’s Light Foundation may use the name of any Patient receiving a Miracle Moment for publicity purposes. Any Referral Form submitted is subject to the Landon’s Light Foundation privacy policy as found on our website at http://www.landonslight.org. *

ACKNOWLEDGED AND AGREED

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