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Please choose the location nearest the room applicant's home: *Mason City, IAWaterloo, IAFort Dodge, IAFort Collins, COHarpswell, MEMiddleton, IDMankato, MNEligible homes are within 30 miles of Mason City, Iowa, or Waterloo, IA

Applicant's First Name *

Applicant's Last Name *

Room Applicant's Date of Birth *

Applicant's Age *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country

Applicant's Phone *

Email Address *

Place of employment

Is the applicant the owner of the property listed on this application? *YesNoIf NO, MHH must have landlord's contact info. in order to get permission to redecorate.

Please list any children and their ages

If married, please provide spouse's name

Documented Cancer diagnosis: *

Please provide current Cancer treatment: *

Are there any additional hardships the applicant is experiencing? *

IMPORTANT: Publicity is vital to the growth of our organization. It is through publicity that we gain potential donors as well as applicants. The family will be asked to sign a MEDIA CONSENT form if chosen for a bedroom makeover. *I understand

IMPORTANT: You may be asked to submit a Healthcare Professional Form, verifying your diagnosis. While we know this can hold up an application, we must have one on file before any work is done on the room (if this form is required by the MHH Affiliate). You may submit the actual application asap, but if application is accepted, this form must be completed by the applicant's healthcare team before any work is done on the room. You may print off this form to take to your healthcare provider to have them sign and mailing it to the MHH Affiliate's address or direct the healthcare provider to: https://myhappyhavenmc.com/healthcare-professional-form/

Name of the person Filling out this application *

Relationship to nominee:

Relationship to the person you are nominating

Phone number of the person filling out this application *

I confirm that all of the above information is true and correct by submitting this application. *Confirm