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Register here to order free My Special Aflac Ducks for your pediatric patients with cancer and blood disorders such as sickle cell. Order as many and as often as you need.

My Special Aflac Duck® is a robotic companion created by Aflac and available to children age 3 and up who have been diagnosed with cancer or a blood disorder such as sickle cell. This comforting companion is available free-of-charge.

My Special Aflac Duck is only available to pediatric patients with cancer and a blood disorder such as sickle cell at the request of an authorized member of their healthcare team located at a licensed healthcare facility or by an organization/non-profit that serves pediatric cancer and sickle cell anemia patients.

If you work at a licensed healthcare facility or organization/non-profit in the U.S. and would like to request authorization to order My Special Aflac Duck, please complete this form in its entirety. We'll notify you of your approval status within a week if we don't require additional information.

If you would like to learn more about My Special Aflac Duck, please visit www.myspecialaflacduck.com

or email a member of our team - we'll be happy to answer your questions!

Buffy Swinehart - Sr. Manager, Corporate Social Responsibility - Aflac - [email protected]

Alayne Gamache - Manager, Corporate Social Responsibility - Aflac- [email protected]

Mandy Flynn - Manager, Corporate Social Responsibility - Aflac - [email protected]

What is the name of your Healthcare Facility/Organization?

Is your facility/organization a 501c3?

Organization Federal Tax ID # (EIN)

Organization Mailing Address

City Location

State Location

Zip Code

Is your organization a Children's Miracle Network Hospital?

Is your organization a Children's Oncology Group (COG) hospital?

How did you hear about My Special Aflac Duck?required

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Information of individual requesting permission to order

First Namerequired

Last Namerequired

Work Numberrequired

Work Emailrequired

I am a licensedrequired

My Title and Departmentrequired

My License Number (if none, type NA)required

Would you like to opt in to receive the quarterly Aflac Childhood Cancer Campaign newsletter?required

My Special Aflac Duck is approved for children with cancer and blood disorders such as sickle cell ages 3 and up. By submitting this form, you are stating that you are an employee of a licensed healthcare facility or organization and have been authorized to order My Special Aflac Duck<> on behalf of childhood cancer and blood disorders patients being served by your facility or organization. You will be notified of your approval status within a week of submission if additional information is not required. Thank you. For additional information, please email us at [email protected] or visit http://www.MySpecialAflacDuck.com.

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I submit this form for approval as an employee of a licensed healthcare facility/organization that currently serves pediatric oncology and/or blood disorders patients..

Aflac l Aflac New York l WWHQ l 1932 Wynnton Rd l Columbus, GA 31999

Z2200106 EXP 02/23

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