Sign up to attend the Annual DC Candlelighters Holiday Event!
Come join us on Sunday, December 10, 2023 between 4:00-5:00 at Centreville Presbyterian Church (15450 Lee Hwy, Centreville, VA). Once you've made a stop at the Church for your gifts and visit with Santa, you will be able to head over to the Bull Run Festival of Lights for the drive-though lights! Please note that your child must be in active treatment for a pediatric cancer, or no more than 12 months off treatment. Be sure to complete the form carefully to ensure your registration. Upon completion of the form, you can expect to receive a confirmation email almost immediately from Jotform that your registration was received (check spam if not received). A second email will be sent to you no later than December 7, 2023, from dccandlelighters@gmail.com with additional details about the event. If you have any questions, please contact us at DCCandlelighters@gmail.com. Please DO NOT submit the form more than one time. Thank you and we look forward to seeing you in December!
Full Name of ONCOLOGY PATIENT (list the child who is/was in cancer treatment):
*
Child's First Name
Child's Last Name
Oncology Child's Age:
*
Oncology Child's Gender:
*
Parent/Guardian Name:
*
Parent/Guardian First Name
Parent/Guardian Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
List the clinic or hospital where your child is/was receiving treatment:
*
Please list name of clinic, hospital, or doctor's name
Date of Diagnosis
*
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Month
-
Day
Year
Approximate date is fine. Doesn't have to be exact.
Date Treatment Ended (if treatment has completed)
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Month
-
Day
Year
Approximate date is fine. Doesn't have to be exact.
Name, Age & Gender of Sibling #1 Attending:
Example: Sally Age 5, Girl
Name, Age & Gender of Sibling #2 Attending:
Example: William, Age 9, Boy
Name, Age & Gender of Sibling #3 Attending:
Be sure to include NAME, AGE & GENDER
If more than 3 siblings are attending, please add their NAMES, AGES & GENDERS here:
EXAMPLE: Kyra, Age 3, Girl; John, Age 8, Boy, etc
Submit
Should be Empty: