Healing with Smiles – KeepSmiling Alliance

Please complete this form to have a stuffed hippo (Buttercup) sent to someone you know with a life threatening illness and share a smile.

Please fill in all the areas on the form and click on the "Send" button.
* Denotes required information.

*Sponsor/Contact Name:

*Street Address:

*City:

*Province:

*Postal Code:

*Day Telephone:


*Night Telephone:


*E-mail Address:

*Recipient Name:

*Street Address:

*City:

*Province:

*Postal Code:

*Day Telephone:


*Night Telephone:


*E-mail Address:

*Gender:
Male Female

*Age:
0-3 4-12 13+

*Shipping Address:

*Recipient’s Story:

      

 

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