REFERRAL FORM

[et_pb_section fb_built=”1″ fullwidth=”on” admin_label=”Header Section” _builder_version=”4.16″ background_color=”#000000″ bottom_divider_style=”ramp” bottom_divider_color=”#e8b247″ bottom_divider_flip=”horizontal” animation_style=”fade” animation_starting_opacity=”90%” locked=”off” global_colors_info=”{}”][et_pb_fullwidth_header subhead=”Referral Form” text_orientation=”center” button_one_text=”Resources” button_one_url=”http://jakesdragonfoundation.org/resouces/” button_two_text=”Make a Donation” button_two_url=”https://give.acco.org/give/182363/#!/donation/checkout” content_max_width=”640px” _builder_version=”4.16.1″ title_font=”Oswald|||on|||||” title_text_color=”#000000″ title_font_size=”20px” title_letter_spacing=”3px” title_line_height=”1.5em” content_font=”Lora||||||||” content_font_size=”22px” content_line_height=”2em” subhead_font=”Lora|700|||||||” subhead_text_color=”#FFFFFF” subhead_font_size=”60px” subhead_line_height=”1.5em” background_enable_color=”off” use_background_color_gradient=”on” background_color_gradient_direction=”174deg” background_color_gradient_stops=”rgba(255,255,255,0) 24%|#000000 81%” background_color_gradient_overlays_image=”on” background_color_gradient_start=”rgba(255,255,255,0)” background_color_gradient_start_position=”24%” background_color_gradient_end=”#000000″ background_color_gradient_end_position=”81%” background_image=”http://jakesdragonfoundation.org/wp-content/uploads/2022/03/Misty-scales-banner.png” custom_button_one=”on” button_one_text_size=”16px” button_one_text_color=”#000000″ button_one_bg_color=”#e8b247″ button_one_border_width=”15px” button_one_border_color=”rgba(210,159,104,0)” button_one_border_radius=”100px” button_one_letter_spacing=”3px” button_one_font=”Oswald|||on|||||” button_two_border_color=”rgba(0,0,0,0)” custom_margin=”|||” custom_padding=”90px||90px||true” animation_style=”fade” animation_duration=”2000ms” animation_starting_opacity=”34%” subhead_font_size_tablet=”” subhead_font_size_phone=”50px” subhead_font_size_last_edited=”on|desktop” button_one_border_radius_hover=”100px” button_one_bg_color_hover=”#cc8d66″ button_two_bg_color_hover=”#d29f68″ global_colors_info=”{}” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_one_border_radius__hover_enabled=”on” button_one_border_radius__hover=”100px” button_two_border_radius__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_one_bg_color__hover_enabled=”on” button_one_bg_color__hover=”#cc8d66″][/et_pb_fullwidth_header][/et_pb_section][et_pb_section fb_built=”1″ admin_label=”Contact Section” _builder_version=”4.16″ background_color=”#e8b247″ use_background_color_gradient=”on” background_color_gradient_direction=”0deg” background_color_gradient_stops=”#ffffff 50%|#e8b247 50%” background_color_gradient_start=”#ffffff” background_color_gradient_start_position=”50%” background_color_gradient_end=”#e8b247″ background_color_gradient_end_position=”50%” custom_padding=”120px|0px|80px|0px|false|false” animation_style=”fade” animation_starting_opacity=”90%” global_colors_info=”{}”][et_pb_row admin_label=”Contact Form Row” _builder_version=”4.16″ background_color=”RGBA(255,255,255,0)” use_background_color_gradient=”on” background_color_gradient_stops=”rgba(255,255,255,0) 0%|#262626 17%” background_color_gradient_overlays_image=”on” background_color_gradient_start=”rgba(255,255,255,0)” background_color_gradient_end=”#262626″ background_color_gradient_end_position=”17%” background_image=”http://jakesdragonfoundation.org/wp-content/uploads/2022/03/AdobeStock_254536479-Red-Dragon-Scales-scaled.jpeg” custom_margin=”-28px|auto||auto||” custom_padding=”80px|40px|80px|40px|true|true” locked=”off” global_colors_info=”{}”][et_pb_column type=”4_4″ _builder_version=”4.16″ custom_padding=”|||” global_colors_info=”{}” custom_padding__hover=”|||”][et_pb_text admin_label=”Title” _builder_version=”4.16″ text_font=”Lora||||||||” text_font_size=”18px” text_line_height=”2em” link_font=”||||||||” ul_font=”||||||||” ol_font=”||||||||” quote_font=”||||||||” header_font=”||||||||” header_2_font=”Lora|700|||||||” header_2_font_size=”50px” header_2_line_height=”1.5em” header_5_font=”Oswald|||on|||||” header_5_text_color=”rgba(255,255,255,0.4)” header_5_font_size=”20px” header_5_letter_spacing=”3px” header_5_line_height=”1.7em” text_orientation=”center” background_layout=”dark” max_width=”750px” module_alignment=”center” custom_padding=”||0px|||” text_line_height_last_edited=”off|desktop” header_2_font_size_tablet=”” header_2_font_size_phone=”36px” header_2_font_size_last_edited=”on|desktop” global_colors_info=”{}”]

How Can We Help You?

[/et_pb_text][et_pb_contact_form email=”bulldogmchugh@comcast.net” submit_button_text=”SUBMIT” module_id=”et_pb_contact_form_0″ _builder_version=”4.16.1″ _unique_id=”ca370cdf-6d70-4792-90a7-cca00190ade1″ form_field_text_color=”#ffffff” title_level=”h2″ title_font=”Lora|700||on|||||” title_text_align=”center” title_text_color=”#FFFFFF” title_font_size=”50px” title_line_height=”1.5em” captcha_font=”||||||||” captcha_text_color=”#FFFFFF” form_field_font=”Lora||||||||” form_field_font_size=”16px” max_width_last_edited=”off|desktop” custom_margin=”|||” custom_margin_tablet=”|50px||50px” custom_margin_phone=”|50px||50px” custom_margin_last_edited=”off|desktop” hover_enabled=”0″ border_radii=”on|5px|5px|5px|5px” form_background_color=”rgba(0,0,0,0.1)” global_colors_info=”{}” sticky_enabled=”0″][et_pb_contact_field field_id=”Name_of_person_referring” field_title=”Name of person referring” fullwidth_field=”on” _builder_version=”4.16.1″ form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” border_color_all=”#FFFFFF” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”Phone_number_2″ field_title=”Phone number” field_type=”email” _builder_version=”4.16″ form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}” button_text_size__hover_enabled=”off” button_one_text_size__hover_enabled=”off” button_two_text_size__hover_enabled=”off” button_text_color__hover_enabled=”off” button_one_text_color__hover_enabled=”off” button_two_text_color__hover_enabled=”off” button_border_width__hover_enabled=”off” button_one_border_width__hover_enabled=”off” button_two_border_width__hover_enabled=”off” button_border_color__hover_enabled=”off” button_one_border_color__hover_enabled=”off” button_two_border_color__hover_enabled=”off” button_border_radius__hover_enabled=”off” button_one_border_radius__hover_enabled=”off” button_two_border_radius__hover_enabled=”off” button_letter_spacing__hover_enabled=”off” button_one_letter_spacing__hover_enabled=”off” button_two_letter_spacing__hover_enabled=”off” button_bg_color__hover_enabled=”off” button_one_bg_color__hover_enabled=”off” button_two_bg_color__hover_enabled=”off”][/et_pb_contact_field][et_pb_contact_field field_id=”Email” field_title=”Email” field_type=”email” _builder_version=”4.16.1″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ hover_enabled=”0″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}” sticky_enabled=”0″][/et_pb_contact_field][et_pb_contact_field field_id=”Name_of_patient” field_title=”Name of patient” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Parents/Guardian_names” field_title=”Parents/Guardian names” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Diagnosis” field_title=”Diagnosis” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Treating_hospital” field_title=”Treating hospital” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Hospital_social_worker/Childlife_specialist_name” field_title=”Hospital social worker/Childlife specialist name” fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Phone_number” field_title=”Phone number” required_mark=”off” _builder_version=”4.16.1″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Email_2nd” field_title=”Email” field_type=”email” _builder_version=”4.16.1″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ hover_enabled=”0″ border_radii=”on|10px|10px|10px|10px” global_colors_info=”{}” sticky_enabled=”0″][/et_pb_contact_field][et_pb_contact_field field_id=”What_can_we_help_you_with?_2″ field_title=”What can we help you with?” field_type=”select” select_options=”%91{%22value%22:%22A bill%22,%22checked%22:0,%22dragID%22:-1},{%22value%22:%22Gift card support %22,%22checked%22:0,%22dragID%22:0},{%22value%22:%22Everyday items%22,%22checked%22:0,%22dragID%22:1}%93″ fullwidth_field=”on” _builder_version=”4.16″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Other_(please_describe)” field_title=”Other (please describe)” field_type=”text” required_mark=”off” fullwidth_field=”on” _builder_version=”4.16.1″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ global_colors_info=”{}”][/et_pb_contact_field][et_pb_contact_field field_id=”Is_there_anything_else_we_should_know_about_your_situation?” field_title=”Is there anything else we should know about your situation?” field_type=”text” required_mark=”off” fullwidth_field=”on” _builder_version=”4.16.1″ _module_preset=”default” form_field_background_color=”#FFFFFF” form_field_text_color=”#000000″ global_colors_info=”{}”][/et_pb_contact_field][/et_pb_contact_form][et_pb_text _builder_version=”4.16″ _module_preset=”default” text_font=”Lora||||||||” text_text_color=”#FFFFFF” text_line_height=”1em” custom_padding=”||2px|4px||” global_colors_info=”{}”]

All requests will be reviewed by Jake’s Dragon Foundation committee for approval.Families can receive support once per year.

We reserve the right to make exceptions, depending on available funds and specific family situations.

 

[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section][et_pb_section fb_built=”1″ _builder_version=”4.16″ _module_preset=”default” background_color=”#f2f2f2″ use_background_color_gradient=”on” background_color_gradient_direction=”178deg” background_color_gradient_stops=”#000000 0%|rgba(255,255,255,0) 66%” background_color_gradient_overlays_image=”on” background_color_gradient_start=”#000000″ background_color_gradient_end=”rgba(255,255,255,0)” background_color_gradient_end_position=”66%” background_image=”http://jakesdragonfoundation.org/wp-content/uploads/2022/03/Misty-scales-banner.png” parallax=”on” saved_tabs=”all” locked=”off” global_colors_info=”{}”][et_pb_row column_structure=”1_3,1_3,1_3″ _builder_version=”4.16″ _module_preset=”default” locked=”off” global_colors_info=”{}”][et_pb_column type=”1_3″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_text _builder_version=”4.16.1″ _module_preset=”default” text_font=”Lora||||||||” header_font=”Lora||||||||” locked=”off” global_colors_info=”{}”]

Jake’s Dragon Foundation
76 W Third Ave                                                Collegeville PA 19426                                      484-294-1109

[/et_pb_text][/et_pb_column][et_pb_column type=”1_3″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][/et_pb_column][et_pb_column type=”1_3″ _builder_version=”4.16″ _module_preset=”default” global_colors_info=”{}”][et_pb_image src=”http://jakesdragonfoundation.org/wp-content/uploads/2022/03/Screenshot-6.png” alt=”This site is powered by Jake’s very own Razorwhip Technology . TM” align=”center” _builder_version=”4.16″ _module_preset=”default” transform_scale=”108%|108%” transform_translate=”46px|0px” width=”71%” custom_margin=”||5px|||” custom_padding=”|19px||||” border_radii=”on|15px|15px|15px|15px” global_colors_info=”{}”][/et_pb_image][et_pb_text _builder_version=”4.16″ _module_preset=”default” text_font=”Lora||||||||” text_line_height=”0.2em” transform_translate=”67px|0px” global_colors_info=”{}”]

 

     This site is powered by

     Jake’s very own

     Razorwhip Technology

[/et_pb_text][/et_pb_column][/et_pb_row][/et_pb_section]