Waiting Room Watcher Request Form

Waiting Room Watcher Request Form

Waiting Room Watcher is a compassionate program that provides dedicated volunteers to care for the children of our moms during their treatment appointments. This service ensures that our mothers can fully focus on their medical care, knowing their children are safe, engaged, and well-cared for in a nurturing environment.
Who Can Benefit?
- Mothers Undergoing Cancer Treatment: Any member receiving treatment who needs assistance with childcare during appointments.
- Children Aged 0-12: Our volunteers are trained to care for children within the specified age range, ensuring appropriate activities and supervision.
How to Get Started
If you would like to utilize the Waiting Room Watcher service, please follow these steps:
1. Fill Out the Request Form: Complete the Waiting Room Watcher Request Form with your appointment details and child information.
2. Confirmation: You will receive a confirmation email within 24 hours with details about your assigned volunteer.
3. Meet Your Watcher: Your assigned Waiting Room Watcher will meet you and your children at the designated location and time of your appointment.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Are you a member of My Sister's Keeper?*

YesNo
Have you completed the client service agreement form?*

YesNoUnsure
A signed Client Service Agreement is required for this service. If you are unsure if you have completed this agreement or have not completed this agreement, please click here to review and sign the agreement - https://www.jotform.com/sign/243245850121044/invite/01jd5h371bf8fb328c601d9a8f . This link will also display after this request has been submitted.
Do you have documentation of your cancer diagnosis on file with My Sister's Keeper?*

YesNoUnsure
This service is only available to women diagnosed with cancer. Proof of diagnosis is required for this service.
Upload proof of diagnosis. This can be in the form of an after visit summary, a treatment plan provided by your provider, a letter from your provider or social worker, or screenshot of appointment that lists department and service (i.e., infusion/chemo/radiation therapy)

Cancelof

Appointment Details
Name of Facility
Department
Location/Building/Room Number
Duration/Length of Appt

Number of Children to be Watched
Child(ren)'s Names and Ages
List Dietary Restrictions. Parents are also encouraged to send snacks with their child(ren).
Anything we should know about your child(ren)? i.e., handicap, special needs, etc.
Upload a photo of your child(ren)*

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In the event of an emergency, you will be the first point of contact. Should you inform us to call the emergency contact, please list them here.
Emergency Contact 1

First NameLast Name
Phone Number 1
Please enter a valid phone number.
Emergency Contact 2

First NameLast Name
Phone Number 2
Please enter a valid phone number.
Assigned Watcher
example@example.com
Watcher's Name
Approve/Decline
Response reason
MySKCleEmail
example@example.com
Should be Empty: