LRF Child Referral Form

The
Little Red Foundation

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Who can refer a child?
Out of respect for the privacy of the children and families we serve, eligible children can be referred by one of three sources:

Medical professionals treating the child – doctors, nurses, social workers
A parent or legal guardian of the potential child
The potential child

If you are not eligible to refer a child, please ask the child's family to submit our referral form or contact a LRF affiliate.

Who is eligible?
A child with a life-threatening medical condition, who is under the age of 18 at the time of referral, is potentially eligible for financial support from Little Red Foundation (LRF). Beneficiaries are required to be a citizen of Durham, Orange, Person or Wake County of the state of North Carolina.

LRF may contact the child's treating physician to determine medical eligibility.

Referral Form
Submit the referral form below. A LRF representative will contact you to arrange receipt of your letter of reference from a medical professional who is treating the child (doctor, nurse, social worker, etc). Please do not submit medical information online or via email.

Your information will be reviewed by Little Red Foundation, and you will be contacted within 4weeks of submission.

First Name:
Last Name:
Address Street 1:
Address Street 2:
City:
Zip Code:	(5 digits)
State:
Daytime Phone:
Evening Phone:
Email:
Relationship to Child:
Photo Release	Please check here to give LRF permission to use your child's name and/or image in our publications.
Comments:	Enter comments here!