Children’s Cancer Network Patient Hero Form

Children’s Cancer Network Patient Hero Form

Share your story or your child’s story to inspire others. Information and photos may be featured on Children’s Cancer Network and Run to Fight Children’s Cancer platforms.
Does the child or family currently reside in Arizona, or was the child diagnosed with or treated for cancer in Arizona?

Hero’s Full Name
Hero’s Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Diagnosis and Date of Diagnosis
Parent’s Full Name
Parent’s Phone
Please enter a valid phone number.Format: (000) 000-0000.
Parent’s Email
example@example.com
Tell us about you! (Share favorite activities, foods, hobbies, sports, or anything else people should know about you.)
Tell us about your childhood cancer journey (Include your diagnosis, treatment experience, important milestones, and where you are today.)
What has helped you and your family remain strong throughout your journey? (Share about family, friends, hospital staff, community, or something special that brings hope.)
What would you like others to know about you or about childhood cancer? (Share an encouraging message, something you wish people understood, or advice for another child or family.)
Hero Photo (Upload a photo of the hero. Please avoid using a cropped photo)

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Parental consent for use of information/photo for social media

Thank you for your interest in Children’s Cancer Network’s September Heroes campaign.

At this time, submissions are limited to children or families who currently reside in Arizona or children who were diagnosed with or treated for cancer in Arizona.
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