New Family Form
Children's Cancer Connection (CCC) is here to help you through your journey. Our resources, services and programs are free and available when you feel the time is right to participate. In order to become an enrolled CCC family, the oncology patient must be living, diagnosed or treated (at any point throughout their treatment) in the state of Iowa. Please complete the form below to become a CCC family.
Oncology Patient
Child's Name
*
First Name
Last Name
Gender
*
Female
Male
Other
Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Diagnosis
*
Treatment Facility
*
Blank Children's Hospital
University of Iowa Stead Family Children's Hospital
Nebraska Children's
Sanford Children's Hospital
Mayo Clinic
Other
Month & Year of Diagnosis
*
Child's Date of Birth
*
Please select a month
January
February
March
April
May
June
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August
September
October
November
December
Month
Please select a day
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Day
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Year
Graduation Month & Year
Child primary lives with:
*
Both parents, in the same home.
Mom only
Dad only
Both parents, in different homes
Other
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Parents/Guardians
Parent/Guardian #1 Full Name
*
First Name
Last Name
Prefix
Mr.
Mrs.
Ms.
Other
Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
*
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Employer
Parent/Guardian #2 Full Name
First Name
Last Name
Prefix
Mr.
Mrs.
Ms.
Other
Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Does this parent/guardian live at the same address as listed for parent/guardian #1?
Please Select
yes
no
Address
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
County
Phone Number
Please enter a valid phone number.
Email
example@example.com
Employer
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Siblings
If your family has more than 4 siblings, please email programs@ccciowa.org
How many siblings live in the household with the oncology patient?
Please Select
0
1
2
3
4
5+
Sibling' #1 - Name
*
First Name
Last Name
Sibling #1 - Gender
*
Female
Male
Other
Sibling #1 - Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Sibling #1 - Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
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5
6
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12
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
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1922
1921
1920
Year
Sibling #1 - Graduation Month & Year
Sibling # 2 - Name
*
First Name
Last Name
Sibling #2 - Gender
*
Female
Male
Other
Sibling #2 - Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Sibling #2 - Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
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31
Day
Please select a year
2025
2024
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2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
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2008
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1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
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1979
1978
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1972
1971
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1962
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1924
1923
1922
1921
1920
Year
Sibling #2 - Graduation Month & Year
Sibling #3 - Name
*
First Name
Last Name
Sibling #3 - Gender
*
Female
Male
Other
Sibling #3 - Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Sibling #3 - Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
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1956
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1954
1953
1952
1951
1950
1949
1948
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1945
1944
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1941
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1935
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sibling #3 - Graduation Month & Year
Sibling #4 - Name
*
First Name
Last Name
Sibling #4 - Gender
*
Female
Male
Other
Sibling #4 - Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Sibling #4 - Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
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20
21
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23
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25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
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1963
1962
1961
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1952
1951
1950
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1948
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1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Sibling #4 - Graduation Month & Year
Sibling #5 - Name
*
First Name
Last Name
Sibling #5 - Gender
*
Female
Male
Other
Sibling #5 - Ethnicity
Caucasian
Hispanic/Latino
Black/African American
Asian
Indigenous American
Native Hawaiian/Pacific Islander
Choose not to disclose
Other
Sibling #5 - Date of Birth
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
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1955
1954
1953
1952
1951
1950
1949
1948
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1945
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1941
1940
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1934
1933
1932
1931
1930
1929
1928
1927
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1924
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1922
1921
1920
Year
Sibling #5 - Graduation Month & Year
For any additional siblings, please list their full name, date of birth and graduation year.
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By signing below, I acknowledge that the individually identifiable information that I am providing to Children's Cancer Connection does not constitute protected health information as that term is defined by the Health Insurance Portability and Accountability Act (HIPAA). I understand that while Children's Cancer Connection will use commercially reasonable efforts to project such individually identifiable information, such information is not protected by HIPAA when it is used or displaced by Children's Cancer Connection.
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