Childhood Cancer Form

1
Have you filled out a participant form in the past?
YESNO
2
Childs Name* This field is required.
3
Childs Date of Birth* This field is required.
Date
Month
Day
Year
4
Child's Gender* This field is required.
Male
Female
5
Childs Ethnicity* This field is required.
6
Diagnosis* This field is required.
7
Currently in Treatment? Date of Diagnosis
Date
Month
Day
Year
8
Treatment Plan (please select all that apply):* This field is required.
Chemo
Radiation
Surgery
Stem Cell
Immunotherapy
Other
9
Where is your child being treated* This field is required.
10
Is your child receiving (please circle all that apply):* This field is required.
SNAP
Medicaid
Medicare
WIC
Other
11
Parent/ Guardian Name (1)* This field is required.
12
Address* This field is required.
13
Mobile* This field is required.
14
Email* This field is required.
example@example.com
15
Preferred Mode of Communication:* This field is required.
Text
Phone Call
Email
16
Gender* This field is required.
17
Marital Status* This field is required.
18
Parent/ Guardian Name (2)
19
Address
20
Mobile
21
Email
example@example.com
22
Preferred Mode of Communication:
Text
Phone Call
Email
23
Gender
24
Parent (s) Ethnicity
25
Marital Status
26
Please list the names/phone numbers/relationship of other adults that may participate in our activities:* This field is required.
27
Name/Age
28
Name/Age
29
Name/Age
30
Name/Age
31
Please tell us how you learned about the ECWC:* This field is required.
32
Is there something specific that you hope to receive for your child at the ECWC (i.e. wig; support group: exercise programs: nutrition: etc.)?* This field is required.
33
Transportation Needs:
I can arrange my own transportation.
I need assistance with transportation- (ECWC may be able to support in the future.)
I am interested in virtual options.
34
Emergency Contact* This field is required.
35
Phone Number* This field is required.
36
Relationship* This field is required.
37
What are the family's primary wellness goals?
Physical Activity
Emotional Support
Nutrition Guidance
Educational Workshops
Social Connection
Stress Management
unsure
other
38
What programs interest you?
Support Groups
Reiki-for those in treatment
Meditation/Mindfulness
Nutritional Workshops
Art Therapy
Journaling
Movement Classes
Wig Salon
Other
39
Preferred Program Times
Weekday AM
Saturday
Weekday PM
Weekday afternoons
Sunday
unsure
Other
40
Photo Waiver: We want the community to see the great things we're doing at the ECWC. This will sometimes require pictures to be taken while classes are in session. Please indicate if we have your approval to take pictures where your face may or may not be visible.* This field is required.
Yes or No
41
Consent and Release: By submitting this form to the ECWC, I understand the following: It is my/our responsibility to clear my/our child's participation at the ECWC with his/her physician if he/she is receiving medical care. I/we represent that the activities that I/we register our child and ourselves for will be those that are appropriate for our physical condition and if they become beyond our abilities, I/we will ask for a modification or stop the activity. Our participation in all classes or services is voluntary and I/we consent to participate. I/we agree to hold Erie Cancer Wellness Center class(es) and/or its services, its directors, officers, employees and agents harmless from all liability and claims arising out of or in connection with my/our participation in classes/services. I/we hereby release and discharge ECWC from all liability arising out of or in connection with the class(es) and/or services. I/we understand that I/we are solely responsible for any loss or injury suffered by me, my child or my property resulting from our participation in classes/services. I/we understand that the employees and providers of the ECWC are mandated reporters and are required to report any suspected abuse/neglect to the authorities.
Should be Empty: