Click to Donate Today 262-308-2894
PO Box 871, West Bend, WI 53095
501(c)(3) NONPROFIT ORGANIZATION

Request for Gift of Love

Please fill out the fields below to refer* a patient, family member or friend to be considered for a Gift of Love:

Note: You may have to switch to Chrome (not Internet Explorer) in order for the “Date of Diagnosis” field to populate correctly. If you continue to have problems, you can also submit without filling in the date.


Name of person being referred:

City where person being referred lives:

Contact Phone #

Indicate
 Cell Home Work

Best Time To Contact
 Morning Afternoon Evening

Okay to leave a voicemail
 Yes No

Please confirm that person you are referring has consented to be contacted by a Chix 4 A Cause representative

 Yes No

Date of Diagnosis

Currently Going through treatment

 Yes No

What would you like us to know about the person you are referring

Referred By

Phone #

Email

Chix 4 a Cause respects and upholds the confidentiality of all people referred to us for help.

* All referrals are evaluated by the Gifts of Love team and then brought before the Chix 4 a Cause Board of Directors for approval of a one-time gift. You can expect to hear from a Gifts of Love team member within two weeks.

Watch Our Video

Gifts of Love Testimonials

“I hardly know where to begin to thank you and your organization for the most generous gifts your gave us. Most of all, it was the warmth that you brought into our live. We were dumb-founded, and yet, grateful for you and the other volunteers to take the time out of your day for us. We have never been so blessed with the very kindness of strangers who touched our hearts. Thank you.”
—Al & Dorothy & family

PO Box 871 West Bend, WI 53095 262-308-2894info@chix4acause.org