Register a Monkey

If you don't already have your kit, please use the link below to request a monkey.

Get a Monkey

Please fill in the form below to register your child's monkey pack. By registering your kit, you will receive access to Monkey Messenger to stay connected with your classroom in a fun and interactive way, receive new items periodically and be included in fun contests and news.

Fields with * are required.

Parent's Information

First Name *

Last Name *

Email *

Phone Number

Address *

City *

State/Province *

Zip/Postal Code *

Country *

Are you the child's legal guardian? *	If you are not the legal guardian, please contact us prior to filling out the form.

Child's Information

Name *

Age *

Child's Birth Month

Child's Birth Year

Diagnosis *

Website	(i.e. CaringBridge, Care Pages, Facebook)

Hospital *	If your hospital is not listed, please email heidi@lovechloefoundation.org

School's Information

School's Name *

School Address

School City

School State

School Zipcode

School Country

Teacher's Name *

Teacher's Email

Grade *

Additional Information

Where did you hear about us *

Other

Do you already have a kit? *

Comments

Please check here if you would like to receive a custom birth certificate for your monkey!
Monkey Name

Monkey Birth Date

I have read and agree with the HIPAA terms located at http://www.monkeyinmychair.org/hipaa and attest that I am the legal guardian of the applicant for the program.