Support Nomination Form

Is your family going through a challenging time? If your child has recently been diagnosed with a medical condition, is scheduled for surgery or a hospital stay, or if you or someone you know has welcomed a baby with medical complications, we may be able to help.

As a Sonoma County resident, you could be eligible for one of our hospital bags, designed to provide comfort and support during this difficult period.

Please share your information with us so we can connect you with the resources you need. Remember, you're not alone. We're here to help.
Commongroundsociety.org
Facebook @commongroundsociety
[email protected]

Requested By (First and Last Name) *

Email of Person Requesting *

Phone Number of Person Requesting *

Relation to nominee *

Nominee's First and Last Name *

Nominee's Phone Number

Delivery Address (Please include any additional information about drop off) *

What does your nominee need support with? hospital stay? new diagnosis? surgery? *

How old is the person who is receiving the support bag? *

If it's an impending surgery or something in the future, what is the date? *

Who can we follow up with? (Please include full name and phone number if this information differs from the requested persons or nominee) *

Anything else we should know?

I agree to terms & conditions provided by the company. By providing my phone number, I agree to receive text messages from the business.