Child and Family Program

Children's New Participant Form

CHILD AND FAMILY PROGRAM
Please complete this form if you are a parent or guardian of a child/children who is visiting Cancer Support Community Greater San Gabriel Valley for the first time. Once received, a CSC staff member will call you to share more about our services.

If you are an adult visiting CSC for the first time, please also complete our Adult's New Participant Form.
Date*

MonthDayYear
Date
Name of Child 1*

First NameLast Name
Child 1's Date of Birth*

MonthDayYear
Date
Child 1's Gender Identity*

GirlBoyNon-binaryPrefer to not discloseOther
Are there additional children who will be participating?

YesNo
Name of Child 2*

First NameLast Name
Child 2's Date of Birth*

MonthDayYear
Date
Child 2's Gender Identity*

GirlBoyNon-binaryPrefer to not discloseOther
Are there additional children who will be participating?

YesNo
Name of Child 3*

First NameLast Name
Child 3's Date of Birth*

MonthDayYear
Date
Child 3's Gender Identity*

GirlBoyNon-binaryPrefer to not discloseOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian Name*

First NameLast Name
Parent/ Guardian Phone*
Please enter a valid phone number.
May we leave a message at this number?*

YesNo
Parent/ Guardian Email*
example@example.com
Child's Emergency Contact Name:
Child's Emergency Contact Phone Number:
Please enter a valid phone number.
The following questions request demographic information used to inform our funders of the individuals we serve. This information is reported in aggregate.

Cancer Support Community Greater San Gabriel Valley does not discriminate on the basis on race, color, creed, national origin, sex, sexual orientation, religion, age, disability or other legally protected status in admission to, access to, or operations of its programs or services.
Ethnicity

White (not Hispanic)White (Hispanic)Black/ African-American (not Hispanic)Black/ African-American (Hispanic)Asian/ Pacific IslanderAmerican Indian/Alaska Native/First NationsOther
Number in household:
Family Income

Under $25k$25k - $49,000$50k - $74,999$75k - $99,999$100k and up
Type of Insurance

MedicareMedicare and privatePrivate insuranceMedicaidUninsured
How did you hear about us? (select all that apply)

FamilyFriendInternet SearchPhysician (specify)Social Media (specify)Event (specify)Print/ online advertisement (specify)CSC Calendar (where did you see it?)Nurse (specify)Social Worker (specify)Therapist (specify)Other healthcare professional (specify)
Specific Referral Source:
Release for Child/ren’s Participation in Children and Family Programs

Read and review the below Children and Family Program Policies. By signing below, I give permission for my child to participate in Children and Family Programs at Cancer Support Community (CSC).
- I understand that my child/ren will be exposed to age-appropriate medical terminology, including the words, “cancer, “chemo”, and “radiation”.
- I understand that my child/ren will be learning social and emotional concepts and coping skills related to such stress, anger, sadness, isolation and grief.
- I understand that I should refrain from bringing my child/ren to CSC if they are sick.
- I understand that though CSC provides structured play and social activities, its purpose is centered on educating and supporting children whose lives have been touched by cancer through support and expressive play activities.
- I understand the importance of notifying staff of any significant changes in my child/ren’s life.
- I understand that if necessary, staff may request a family meeting to discuss my child/ren’s needs as well as their appropriateness for the program.
- I understand that while my child/ren is in an activity, I (or my designated substitute) am to remain in the building unless otherwise specified.
- At CSC, confidentiality is promised to children, except in situations where they or another person might be endangered. I understand that while CSC encourages respect for privacy CSC has control only over staff and volunteers. CSC cannot guarantee confidentiality between members.
- Participation in any activities at CSC is entirely voluntary, and is not a required condition of my child/ren’s membership.
- I have been advised to consult my child/ren’s physician, or other healthcare professional, before having them participate in any physical activities and to follow their physician’s, or other healthcare professional’s advice with respect to such activities.
- Any recreational or physical activity involves some risk of injury, whether apparent or not, and by participating in any such activity I assume all risks for my child/ren, known or unknown, whether foreseeable or not.
- In consideration of CSC’s assent to the use of its premises and/or facilities for non-employment related recreational and physical activities, I release CSC of any and all liability for any injury or damages resulting from or incurred in connection with my child/ren’s participation in any recreational and/or physical program except to the extent that such injury or damages are caused by gross negligence on the part of CSC, and I agree to indemnify and hold CSC harmless with respect to any claim rising from any intentional or negligent conduct on my child/ren’s part.
I give permission for my child/ren to participate in Children and Family Programs at Cancer Support Community and agree to the above policies.*

YesNo
Parent/ Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Children's New Participant Form