Project Smiley referral form.

Please fill out the form below with the referral's information, not your own (unless you are filling out the form for yourself).

MEDICAL INFORMATION

Please answer all of the following questions that pertain to the medical diagnosis. All information is kept confidential.

The mission of The Smiley Fund is to bring joy, comfort, and meaningful experiences to young adults facing cancer. While we focus on granting smiles through trips, adventures, and special experiences, some of our services may also involve wellness-related activities.

Before beginning any experience that includes a therapeutic or wellness component, we require applicants to consult with their primary oncologist or healthcare provider. If your application is approved, we’ll share access to a list of vetted service providers and instructions on how to schedule and pay for the service you choose — up to our funding cap.

Please note: The inclusion or mention of any service, experience, or practitioner does not constitute an endorsement by The Smiley Fund. None of our offerings are intended to replace medical treatment or advice from your primary healthcare team.

The Smiley Fund does not discriminate in any of its programs or activities on the basis of race, color, national or ethnic origin, ancestry, age, religious creed, disability, sex or gender, gender identity or expression, sexual orientation, military or veteran status, genetic information, or any other characteristic protected by applicable federal, state, or local law.

We are committed to creating inclusive, supportive, and joyful experiences for every individual we serve.

RELEASE AND AGREEMENT

The undersigned participant (hereinafter referred to as "Participant") is requesting the assistance of The Smiley Fund in identifying experiences, services, or providers (collectively referred to as “Experiences”) that may include, but are not limited to: travel, entertainment, adventure, wellness activities, therapeutic services, or other forms of joy-driven support (the "Experience Providers"). The Smiley Fund does not directly provide these services or experiences.

The Participant understands and acknowledges that The Smiley Fund refers only to Experience Providers who are appropriately vetted and, where applicable, licensed and insured. Participants are strongly encouraged to consult with their primary oncologist or healthcare team prior to engaging in any experience, especially those that may have wellness or physical components.

In consideration of The Smiley Fund’s support in connecting the Participant with possible Experiences or Experience Providers:

a) The Participant acknowledges and fully assumes any and all risks, known or unknown, associated with participating in any experience or service facilitated through The Smiley Fund.

b) The Participant, on behalf of themselves and their heirs or legal representatives, agrees to waive, release, and hold harmless The Smiley Fund, including its directors, officers, employees, volunteers, and agents, from any and all claims, losses, damages, or injuries — including death — that may arise from participation in any referred or supported experience.

All personal information, including medical history, identity, and participation in The Smiley Fund programs, will be handled with strict confidentiality in accordance with the Massachusetts Privacy Act and the Health Insurance Portability and Accountability Act (HIPAA).