Childhood Cancer Support Information Form

Please select one of the following:*

You have my approval to use the information in this form to sign up our warrior and family for various services and programs offered by foundations.I would like to request a copy of my responses, as well as a list of the foundations available.
If you are in need of financial assistance, there are a variety of resources available. However, the application processes for financial aid can be quite specific and may vary depending on the type of assistance you require. For those who have requested financial assistance, I will be following up with an email to ensure that I can provide you with the appropriate resources. It's important to note that many of these resources may request communication with you for verification purposes, so please keep a close eye on your email, including your spam or junk folder. For those who have requested I fill out the forms for them: Would you prefer that we communicate via text or email?*

TextEmailCallNot Needing Financial Assistance At This TimeOther (specify at the end in comments)
Comments:
Parent/Legal Guardian 1: *

First NameLast Name
Parent/Legal Guardian 2:

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:*
username@domainname.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Shipping Address (If shipping address is not the same as home address):
If this address is temporary due to treatment please indicate here as well.
Parent Information: Please provide your shirt & botooms size(s), and share some of your favorite things, hobbies, or interests. This information will help us tailor any support or goodies we may send to your preferences and needs.*
What are your T-Shirt Sizes? (for parents)

What Type of Assistance Are You Seeking?*

Financial Assistance (If you require financial support, I will send you a list of resources via email. Many of these resources have specific requirements related to financial details and the type of assistance required. If you need assistance in completing the financial assistance applications, I'm here to assist you with that too!)Smiles & Support for My WarriorSmiles & Support for SiblingsPeer-to-Peer SupportOther (share details in notes)
Notes (If you selected other, please share details here):

Warrior Name:*

First NameLast Name
Warrior DOB:*

MonthDayYear
Nickname:
Do you mind sharing a photo of your warrior?

Cancelof
Diagnosis:*
Risk or Stage of Diagnosis (if known):
Date of Diagnosis:*

MonthDayYear
Approximate Date if unknown on exact.
End of Treatment Date (If Known):

MonthDayYear
Date
Treatment Status:*
Treating Hospital/Facility*
Date of Passing:

MonthDayYear
Date
Warrior Favorites:*
Tell us about your warrior favorites, (color, toys, shows, movies, music, hobbies, and characters.)
Warrior T-shirt, Pant/Short & Shoe Size:*
Warrior Favorite Number & Nickname for back of Jersey
Is there any specific information you would like to provide regarding shoes, such as considerations related to neuropathy or any other relevant details?
Is there anything else you would like us to know about your warrior?
Does Your Warrior Have Any Siblings?*

Sibling Name(s) & Age(s):
Sibling Favorites:
Please share some favorites for siblings!
Sibling Tshirt, Pant/short, & Shoe Size:

Primary Oncologist*

PrefixFirst NameLast Name
Oncologist Number:
If KnownFormat: (000) 000-0000.
Oncologist E-Mai:
If Known
Social Worker Name:

First NameLast Name
Social Worker Phone #:
Please enter a valid phone number.Format: (000) 000-0000.
Social Worker E-Mail:
example@example.com
Child Life Specialist Name:

First NameLast Name
Child Life Specialist Phone:
Please enter a valid phone number.Format: (000) 000-0000.
Child Life Specialist E-Mail:
example@example.com

Share Your Journey!
Do you have a Facebook, Instagram, or website where you share updates about your child? We'd love to follow along and provide support to your child and your family. If you have any of these, please share the details. Your personal page is also acceptable if that's your preference.
Are you comfortable with allowing all non-profit organizations to share your child's story and pictures on their social media accounts or platforms?*

I confirm that the information about, First Name* Last Name* is accurate and correct. I have reviewed the form and will monitor my email for any additional information that may be required. Yes
Signature
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