The Singletons 2023 Parent Intake Form

The Singletons Family Registration

2023 Parent Intake Form
Welcome!

We are so grateful you found the Singletons. You are on your way to receiving the practical support you need during this difficult time. To help begin the process please complete this form below.
For assistance with this form, or or if you have additional questions, contact us directly at (480) 818-5285 or email us at Families@TheSingletonsAZ.org

2832 E Bell Rd.
Phoenix, AZ 85032
p. (480)818-5285
e. families@thesingletonsaz.org
www.thesingletonsaz.org

The Singletons is a 501c3 non-profit organization.
Federal Tax ID # 35-2280372
EnglishEspañolOther
Today's Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
PhoneEmailTest Message / SMSOther
SingleMarriedDivorcedLegally SeparatedCo-Habitation (living with adult partner)Other
Dependents

At least 50% custody living in the home under the age of 18
How many dependents under the age of 18 currently live with you?*
Must be under 18 years old to be considered a dependent
Child/Dependent #1 *
Child/Dependent #2
Child/Dependent #3
Child/Dependent #4
Child/Dependent #5
Child/Dependent #6
Child/Dependent #7
Child/Dependent #8
Child/Dependent #9
Emergency Contact Information*
The Singletons has a meal program. Do you or any of your children have food allergies, or dietary restrictions?*
Treatment Profile

For internal use only. Data collected is not shared externally with outside third outside parties.
NoYesMaybe or depends on the opportunityOther
Social ServicesPhysician, Clinic or Hospital (PCP, Oncologist...etc.)NewsSocial MediaGooglePersonal Referral / Word of MouthOther
SelfChild
What is your Date of Birth?*
When were you, or your child, diagnosed?*

MonthDayYear
Date of diagnosis
What type of cancer were you or your child diagnosed with?*
(breast, cervical, lymphoma)
What Stage?*
Please list your Oncologist and the location of treatment*
Form of Treatment*
Chemotherapy, Radiation
Frequency (number of sessions) & Course (length) of Treatment? (Example: 2 times per week for 4 weeks) *
Please upload any supporting documentation from your Physician or Specialist regarding your current diagnosis. You can also upload a pic using your camera/phone or email families@thesingletonsaz.org.

Supporting Documentation accepted file types include: pdf, doc, docx, xls, xlsx, csv, txt, rtf, html, zip, mp3, wma, mpg, flv, avi, jpg, jpeg, png, gif
Cancelof
Statistical Reporting

The following information is for statistical purposes only and will not affect your eligibility to receive services from The Singletons. This information compiled is used for grants to fund The Singletons program. Certain statistical information may also be used in The Singletons’ literature, on their website or to educate the public about the population that The Singletons serves.
If you do rent, do you qualify Do you own your home or rent?*
If you rent, do you qualify for subsidized housing?*
If you selected "Other Living Situation", what are your living arranements? Living with friends or family?*
Do you receive any forms of assistance? i.e. Food Stamps, Cash Assistance, Disability, etc.? If so, what type of assistance do you receive?*
Financial Assistance
Do you receive child support?*
Are you currently working? If so, where?*
What is your racial or ethnic heritage?*
Ethnicity or Race
Have you served in the U.S. Military or Armed Forces?*
Should be Empty:

The Singletons Family Registration

Welcome!

Dependents

Treatment Profile

Statistical Reporting