Participant Registration
**Open to Pediatric Cancer patients under 18 years of age and their immidiate families**
Parent or guardian
*
First Name
Last Name
fishing ?
Parent or guardian
First Name
Last Name
fishing ?
child 1
*
Age
First Name
Last Name
Fishing ?
child 2
Age
First Name
Last Name
Fishing ?
child 3
Age
First Name
Last Name
Fishing ?
child 4
Age
First Name
Last Name
Fishing ?
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Have you attended in the past
*
YES
NO
Where did you hear about us
Cancer Care MB
Received package by mail
Facebook
Submit
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