Request A Song

If your child is 21 or younger and is battling a serious physical or emotional medical challenge, you can request a free “song of love” by filling out the form below.

(All fields with an * are required and must be filled in. Please make sure form is completely filled out before submitting it.)

Haga clic aquí para el perfil en Español.

Child Info

Medical Info

Parent or Guardian Info

Where Should Song Be Sent

(Leave blank if same as parent or guardian address)

How Did You Hear Of Songs Of Love?

Publicity Release

I, the undersigned, hereby grant to Songs of Love Foundaton (Songs of Love) the right, license, and privilege to use my name, likeness, photograph, voice, and biography, as well as the "Song of Love" written for the above-named child in such a manner as Songs of Love shall deem appropriate, (including but not limited to fundraising, etc) in order to promote, advertise, and publicize Songs of Love and its charitable activities.
If possible, PLEASE upload a photo of child. (max file size:10mb)

Also, you can download this form for email, fax, or mail by clicking here.
(Not all Firefox browsers support fillable PDF files. If this is the case download the form, fill it out and email it to: songwriter@songsoflove.org.)