Ishan Gala Foundation

New Family Registration- Virginia Only

* First Name

* Last Name

* Email

* Address

* City

* State

* Postal Code

* Mobile Phone

Marital Status

Are you currently employed?

Monthly Household income

Parent 2 (if applicable)

P2 First Name

P2 Last Name

Is parent 2 currently employed?

P2 Email

P2 Phone Number

P2 Address (If different)

Can we contact them if you are unreachable?

Diagnosed child's information

* Child's First name

* Child's Last Name

* Date of Birth

* Child's Favorite food, snacks, drink, etc.

* Child's favorite restaurants

* Child's favorite color

* Child's hobbies and interests

* Diagnosis

* Diagnosis Date

* Primary Hospital for treatment

* Social worker name

* Social Worker Email

* Social Worker Phone Number

* Current stage of treatment

If completed Treatment, please provide month and year treatment was completed

* Are you currently inpatient?

* Do you have any upcoming travel plans for treatment?

Your Journey so far

* Please let us know if you have specific request that is urgent

Sibling Information

Please provide as much information as possible and be as specific as possible so we can ensure that we provide your child with items they will enjoy!

Sibling 1 first name

Sibling 1 last name

Sibling 1 Date of Birth

Sibling 1 favorite snack, candy, treats

Sibling 1 favorite color

Sibling 1 hobbies and interest; characters; books; activities

Sibling 1 favorite restaurant

Sibling 2 first name

Sibling 2 last name

Sibling 2 date of birth

Sibling 2 favorite snack, candy, treats

Sibling 2 hobbies and interest; characters; books; activities

Sibling 2 favorite color

Sibling 2 favorite restaurant

Sibling 3 first name

Sibling 3 Last Name

Sibling 3 Date of Birth

Sibling 3 favorite snack, candy, treats

Sibling 3 hobbies and interest; characters; books; activities

Sibling 3 Favorite color

Sibling 3 favorite restaurant

Sibling 4 First Name

Sibling 4 Last name

Sibling 4 Date of Birth

Sibling 4 favorite snack, candy, treats

Sibling 4 hobbies and interest; characters; books; activities

Sibling 4 Favorite color

Sibling 4 Favorite restaurant

Places you shop

Gas Stations

Grocery Stores

Restaurants and Other food places

Other Gift Cards that may be helpful

Privacy and sharing

Allowing us to share pictures and stories help us:
Raise Awareness and educate about children's cancer

Helps us with securing funding to improve our programs and provide more in the future.

May we share your story?

May we share pictures of your child fighting? (please select sources you are ok with us taking pictures from)

May we share pictures of your whole family?

May we share first names in our stories and with pictures?

Caring Bridge link

Facebook Page

If you are completing this form on behalf of a family, please provide your name, relationship to patient and contact information

The Ishan Gala foundation is here to welcome you into their family to support you through this long, unpredictable journey. We provide financial, emotional, and social support to families with a child under the age of 18. Financial assistance is open to all fighting families in the U.S. All other programs are restricted to fighting families in Virginia.

Programs offered:

Financial assistance- help with bills at home, costs associated with treatment including travel expenses, meals and grocery gift cards.

Holiday Cheer Program- Fulfills wishlists of fighters and siblings for Christmas, grocery gift card for each family and wrapping supplies. Exclusive Holiday party just for fighting families including crafts, food, music and a special guest, Santa.

Extra Mile Program- Provides comfort and joy to lift families up during their journey. This includes comfort packages, birthday treats for each child in your family, special visits and requests.

If you have any questions, reach out to Ashley Cherrix at ashley@ishangala.org or 434-234-4644.