Request a Basket

Request a Basket 2018-09-08T15:33:23+00:00

Rock’n Rooms Basket Qualifications

Your child must meet the two conditions below to qualify for a Rock’n Rooms Basket.

  • Your child must be a patient at a hospital in the Portland Oregon area.
  • Your child must have an extended hospital stay of three or more weeks.
Rock'n Room Baskets

Request a Basket Form

The form takes a few seconds to process. Please wait for the “Form Sent Successfully” message before leaving the page.
You should receive an email that your form was received by us. If you do not, please check your spam folder first, then follow-up with us at 503-970-9432 (General Basket Inquiries 48 hours after submitting a request.)

Child's First Name*
Child's Last Name*
Child's Age*
Parent/Guardian First Name*
Parent/Guardian Last Name*
Parent/Guardian Phone*
Parent/Guardian Email*
Child's Tending Hospital*
Reason for Hospitalization*
Child's Hospital Check-in Date*
Child's Room Number*

Top Three (3) Themes that your child would like:

Additional Comments IE: Child's Special Needs