2023 MitoSantas Application

"*" indicates required fields

Please fill out a separate application for each child. Applications can be submitted for children 18 and younger affected by mitochondrial disease and siblings 16 and younger that are not affected. Please remember that our budget is approximately $50 per child. Applications need to be submitted by October 20, 2023.

Submitting an application does not guarantee admission into MitoSantas. Please have ideas ready when you are contacted by our volunteers later in the season.

Adult Name*

First Last

Email*

Phone*

Shipping Address*

This is the address where your child’s gifts will be sent!

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child Name*

First Last

The following section should be answered about the above named child.

Does this child have mitochondrial disease?*

What is their specific diagnosis?

Does this child have any of the following special needs?*

Blindness

Deafness

Autism

Developmental disabilities

Other

None

Please indicate any additional special needs.*

Birthday*

Favorite Color*

Favorite Characters / Animals*

Favorite Sports Team(s)*

Favorite Snacks / Food Treats*

Please keep in mind that these are items that should be able to be mailed.

Pant Size (Please specify child, youth or adult)*

Shirt Size (Please specify toddler, youth or adult)*

Shoe / Sock Size (Please specify toddler, youth or adult)*

Specific Gift Requests*

Please be as specific as you can – include brand, color, etc. Feel free to include links if available.

General Gift Requests*

Example – art supplies, hair accessories, etc.

Sometimes store pick-up is needed for gifts. Which of these stores, if any, are you able to pick up from? Please select all that apply.*

Target

Walmart

Best Buy

Michaels

None

Would you be willing to make a wish list on any of the following? Please select all that apply.*

Amazon

Walmart

If chosen, we ask that you send us a picture(s) of your child with the gifts so that we can share them with our donors. No identifying information will be shared. Do you agree to allow us to share the pictures on our website, Facebook page or in emails to our donors?*

Phone

This field is for validation purposes and should be left unchanged.

2023 MitoSantas Application

The following section should be answered about the above named child.

Awareness Week

Energy Walk – Boston

Wondering Wednesdays: Ask the Genetic Counselor

Expert Series: LCHADD Retinopathy Update: Moving Toward a Treatment

Expert Series: Immune Cell Function in Mitochondrial Disease

The following section should be answered about the above named child.

Upcoming Events

Expert Series

Upcoming Presentations

Last Presentation

Upcoming
Events

Expert
Series