Wichita's Littlest Heroes "Refer a Hero"

WLH is a non-profit organization for children (Heroes) ages 0-18 in Kansas with one or more life-threatening medical conditions! We are so excited that you have found Wichita's Littlest Heroes and look forward to meeting your Hero family. We love to hear about what makes your family unique and all about your medical journey. WLH is here to ease the everyday burdens and provide HOPE, HELP & HAPPINESS! Our REQUIREMENTS to join are you must live in the state of Kansas, and for your child's illness to meet "life-threatening status." This means without proper medical care and parent support this illness could result in death. Unfortunately, Autism & Downs Syndrome diagnosis ALONE are not diagnosis' we serve, UNLESS there is a secondary medical diagnosis. If you have any questions or concerns please feel free to call or email our office at 316-364-3354 or brianna@wichitaslittlestheroes.com.

Please fill out the following document. Have your child's physician sign and attach the completed form.

Download Form Here: https://bit.ly/3dFxjWy *ELECTRONIC SIGNATURES ACCEPTED*

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Today's Date/Time

Hero Full Name

Hero Date of Birth

Hero Gender

Hero T-Shirt Size

Hero Mailing Address

Street Address, City, State, Zip

County

Primary Contact Full Name

Primary Contact Email

Primary Contact Phone #

Secondary Contact Full Name

ALL Diagnoses

(Please list life-threatening conditions first then all others)

Category of Diagnosis

Select an option

Siblings (Name, DOB, Gender)

ie. John, 01/24/2019, M Jane, 05/22/2000, F

{name}

Hero Ethnicity - Select All That Apply

Select an option

Annual Household Income

Number of Individuals in Hero Household

ie. 3 Adults 2 Children

Which BEST Describes Your Household?

Primary Contact Employer

Secondary Contact Employer

Are you interested in volunteering?

How did you hear about the Heroes?

Select an option

What do you hope to get from being a member of Wichita's Littlest Heroes?

{name}

What challenges does your family face most due to your child's diagnosis?

Select an option

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