Childhoodcancer research funding application for petition

Join the campaign and share your story for Petition.

Fill the form out below fully and accurately to be part of campaign. (Remember we pay for each petition to be created so you don’t have to.)
Full Name*

First NameLast Name
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Child’s name and age of diagnosis?*
Type of cancer and how long has he/she been fighting? (if the are still fighting)*
What type of emotional distress has it caused your child and family?*
Why are you so passionate about joining this campaign?*
Are you willing to stand by Chad if your petition is presented to the house? (In D.C.)*
What do you feel was the hardest part of fighting cancer?*
Do you feel today’s treatment is humane? why or why not?*
Short summary of diagnosis, hardship or child loss to your family? What you have seen with other families?*
Please provide a link to a page that features your child’s fight. (Important as proof via Website, social media, ect…)*
Upload image of Child WITH A LEGAL GUARDIAN. (Remember you want a photo that represents your HARDSHIP fighting cancer)

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Signature for consent to share ALL medical information and personal data provided on this form with our team for the purpose of creating your petition.*

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Join the campaign and share your story for Petition.