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Art From The Heart

Thanks for your interest in getting a dream room makeover. Room makeovers are awarded by lottery at several points each year. Connecticut children ages 4-16 who are currently undergoing treatment for at least six months or who recently completed treatment are eligible, although we do consider exceptions. Once your application has been accepted, we will pair a local team with you to make over your child’s room into the room of his or her dreams through paint, fabric, creativity and boundless imagination. We do not provide structural remodeling. To submit your application, complete the form below. All applications must be reviewed and approved by your social worker. If you have any questions, email us at info@thecircleofcare.org.

Art From The Heart Application
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Information About The Patient
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Country
Address Line 1
City
State
Postal Code
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Is the patient currently in active treatment for cancer?
Is the patient a Connecticut resident?
Patient's Ethnicity
Information About The Family
Primary Parent/Guardian (G1)
What is your relationship to the patient?
Country
Address Line 1
Address Line 2
City
State
Postal Code
Phone Number
ext Extension
Release and Statement of Confidentiality

In consideration for the receipt of any financial assistance or medical equipment that Circle of Care may provide to the applicant and/or the child, applicant agrees on behalf of applicant and the child to release Circle of Care and hold it harmless from any loss, liability, damage, cost or expense arising out of any claim or suits which may be brought or made which in any manner relates to the assistance or equipment provided to the applicant and/or the child as a result of this application. Circle of Care agrees to keep confidential all personal information, records, data, and files of any nature provided to it as a result of applicant’s request for assistance or medical equipment (the “Confidential Matters”). The undersigned acknowledge and agree that all non-identifying demographic information provided in the application may be used by Circle of Care for funding, grant and other similar purposes. Circle of Care agrees not to disclose any Confidential Matters without the prior written consent of applicant.

Applicant acknowledge and agree that Circle of Care may hereafter contact the child’s physician and/or social worker to verify any or all of the information from the application, including but not limited to the child’s diagnosis.

Filling in your name above represents your authorized signature and your desire to have your application submitted to Circle of Care for review.

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