About the Program

The partnership between the Jel Sert Company and the American Childhood Cancer Organization began in 2008 to help promote awareness and sponsor advocacy programs on a national basis and in 2010, The Jel Sert Company initiated the Take a Pop, Share a Smile program. The overarching mission of the program is to help children across the United States cope with cancer and all that it brings to their lives. These brave children face many challenges, such as the side effects of the invasive therapies used to treat the disease. Freezer pops are often used to help children endure these treatments while keeping them hydrated.-

The program involves the donation of freezers and a continuous supply of freezer pops to cancer treatment centers throughout the country. With the help from people like you, The Jel Sert Company has donated over 1 million pops to over 125 centers across the country to date!

Form Submitter Information

I am completing this form because...

I would like more information about the Take a Pop, Share a Smile programI would like to enroll the hospital/facility that I work for in the programI would like to nominate a hospital/facility in my community I do not work for that would benefit from this programI would like to request more freezer pops for our freezer

Your Contact Information

Your First Name

Your Last Name

Your Email

Your Phone Number

Take a Pop, Share a Smile Program Inquiry:

Please provide the following information. Once you complete and submit this form the Take a Pop, Share a Smile Program Coordinator will contact you via your preferred method of communication.

Preferred Method of Contact (Select One)

EmailPhone Call

Your Email

Your Phone Number

Hospital Affiliation (if any)

Additional Information

Nominate a Hospital

Please provide the following information. Once you complete and submit this form the Take a Pop, Share a Smile Program Coordinator will contact the hospital contact listed below to further discuss the program.

Nominated Hospital Information

Hospital Name

City

State

Website

Hospital Contact Name

Title/Position

Hospital Contact Email

Hospital Contact Phone Number

Why are you nominating this hospital?

Enroll my Hospital in the Program

Please provide the following information. Once you complete and submit this form the Take a Pop, Share a Smile Program Coordinator will follow-up with you regarding shipping information.

Hospital Information

Hospital Name

Website

Shipping Address Line 1

Shipping Address Line 2

Country

Provinces

State/Province

City

State

Postal Code

Hospital Contact(s) Information

Contact #1 First Name

Contact #1 Last Name

Contact #1 Title/Position/Department

Contact #1 Email

Contact #1 Phone Number

Contact #2 First Name

Contact #2 Last Name

Contact #2 Title/Position/Department

Contact #2 Email

Contact #2 Phone Number

Order Information

We would like to order:

A Freezer and Unlimited PopsUnlimited Pops ONLY

Department where freezer/pops will be located?

Number of patients per week (in freezer/pops location)?

How will your hospital/facility benefit from this program?

Freezer Pop Replenishment

Thank you for participating in the Take a Pop, Share a Smile program. Please follow the directions below to successfully request more freezer pops!

Please send a replenishment request email to tschilling@jelsert.com. To expedite your freezer pop delivery, please include the following information in your email:

1. Name of organization

2. Shipping address

3. Receiving contact's name

4. Best contact phone number

Contact Information