Sibling Programme Pilot Scheme
1. I/We understand that non identifiable information given below may be used by Beads of Courage UK for statistical analysis and approved 3rd party data sets. This data may also be used to improve the functionality of the Beads of Courage programmes and potentially help direct childhood cancer research in to the areas it is needed the most. This information may also be shared with our oncology programme sponsor, Children with Cancer UK registered charity 298405
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Yes, I understand
No, I do not understand
Please Answer the Following Questions:
2. Do you consent to unidentifiable information sharing with our sponsor, Children with Cancer UK?
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Yes
No
3. Do you consent to giving feedback throughout the pilot scheme?
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Yes
No
4. Do you consent to your patient and sibling images/story being used on Beads of Courage uk's social media?
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Yes
No
5. Do you consent to your patient and sibling images/story being used on Children with Cancer uk's social media?
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Yes
No
6. Would you like to be considered for special/respite day trips or events with either BOCuk or CWCuk?
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Yes
No
7. Would you be interested in being involved in future documentaries/press events for either BOCuk or CWCuk?
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Yes
No
8. Where Did You Hear About the Sibling Programme Pilot Scheme?
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9. Parent/Carer/Legal Guardian *Please Provide First and Last Name*
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10. Parent/Carer/Legal Guardian Email Address (PLEASE ENSURE EMAIL ADDRESS IS ADDED OR BEADS WON'T BE SENT)
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Newsletters
11. Would you like to sign up for BOCuk Newsletter?
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Yes
No
12. Would you like to sign up for CWCuk Newsletter?
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Yes
No
This Section is about the Sibling/s
11. Sibling Name
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12. Sibling Date of Birth. (This pilot Scheme is for ages between 18 months and 18 years)
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Month
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Day
Year
Date
13. Sibling's Favourite Colour
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14. Current Address (PLEASE ENSURE YOU ADD FULL ADDRESS OR BEADS WON'T BE SENT)
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15. Are you applying for more than one sibling? If yes please enter their names, dates of birth and favourite colour below, or they will not be included.
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Yes
No
15a. Additional Siblings (If no additional siblings, please write N/A)
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This Section is about the Patient
16. Patient Name
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17. Patient Date of Birth.
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Month
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Day
Year
Date
18. Patient Diagnosis. What is the exact diagnosis of the patient?
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19. Date of Diagnosis
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Month
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Day
Year
Date
20. Name of Main Hospital Treated at
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21. Name of Shared Care Hospital Treated at
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Submit
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