New Family Registration Form:
By completing this form, you will be registered with Childhood Cancer Foundation of Southern California, Inc. ("CCFSC") and added to the mailing list to receive newsletters, flyers, and special event information. Your information will not be shared with any other organization. FORM MUST BE COMPLETED BY PARENT/LEGAL GUARDIAN.
Con completar esta forma, estarán registrados con La Fundación de Cáncer Infantil y agregaremos su nombre a la lista de envío para que reciba boletines de noticias, volantes, e información sobre eventos especiales. No compartimos su información con ninguna otra organización. EL FORMULARIO DEBE SER COMPLETADO POR EL PADRE / GUARDIAN LEGAL.
Language Preference / Preferencia de Idioma
*
English
Español
PATIENT INFORMATION
Información del Paciente
Full Name
*
First Name
Last Name
Date of Birth / Fecha de Nacimiento
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender / Sexo
*
Male
Female
Non-Binary
Transgender
Intersex
Other
Diagnosis (Type of Cancer) / Diagnóstico (Tipo de Cáncer)
*
Age at Diagnosis / Edad al Diagnóstico
*
Please Select
0-11 months
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
Treatment Facility / Hospital o Centro de Tratamiento:
*
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Parent Information
Información de Padres
Mother's Name / Nombre de la madre:
First Name
Last Name
Mother's Email / Correo Electrónico de Madre:
example@example.com
Mother's Cell Phone Number / Celular de la Madre:
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like to receive text notices about CCFSC events? / ¿Le gustaría recibir avisos por mensaje de texto sobre los eventos del CCFSC?
Yes
No
Mother's Employment / Empleo de Madre:
Father's Name / Nombre del Padre:
First Name
Last Name
Father's Email / Correo Electrónico del Padre:
example@example.com
Father's Cell Phone Number / Celular del Padre:
Please enter a valid phone number.
Format: (000) 000-0000.
Would you like to receive text notices about CCFSC events? / ¿Le gustaría recibir avisos por mensaje de texto sobre los eventos del CCFSC?
Yes
No
Father's Employment / Empleo del Padre:
Primary Contact / Contacto Primario
*
Mother
Father
Other (List Below)
Legal Guardian (If different from above) / Guardián legal (si es diferente al anterior)
First Name
Last Name
Legal Guardian Cell Phone Number / Celular del Guardián legal:
Please enter a valid phone number.
Format: (000) 000-0000.
Guardian Email / Correo Electrónico del Guardián legal:
example@example.com
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Residential Information
Información Residencial
Address / Dirección
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County / Condado
*
Home Phone Number
Format: (000) 000-0000.
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Sibling Information
Información de hermanos
Sibling #1 Name
First Name
Last Name
Sibling #1 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sibling #1 Gender / Sexo
Male
Female
Non-Binary
Transgender
Intersex
Other
Sibling #2 Name
First Name
Last Name
Sibling #2 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sibling #2 Gender / Sexo
Male
Female
Non-Binary
Transgender
Intersex
Other
Sibling #3 Name
First Name
Last Name
Sibling #3 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sibling #3 Gender / Sexo
Male
Female
Non-Binary
Transgender
Intersex
Other
Sibling #4 Name
First Name
Last Name
Sibling #4 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sibling #4 Gender / Sexo
Male
Female
Non-Binary
Transgender
Intersex
Other
Sibling #5 Name
First Name
Last Name
Sibling #5 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sibling #5 Gender / Sexo
Male
Female
Non-Binary
Transgender
Intersex
Other
Sibling #6 Name
First Name
Last Name
Sibling #6 Birth Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sibling #6 Gender / Sexo
Male
Female
Non-Binary
Transgender
Intersex
Other
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Authorizations
I give CCFSC authorization to use pictures of my child for newsletters/brochures, and other printed and/or digital material. / Doy autorización a CCFSC para usar fotografías de mi hijo/a en boletines o folletos y otros materiales impresos y/o digitales.
*
Yes
No
Please add my name to be shared with other oncology families on the CCFSC family list. / Agregue mi nombre para compartirlo con otras familias de oncología en la lista de familias de CCFSC.
*
Yes
No
Would you be available on short notice for tickets to special events (Sporting events, concerts, etc)? / ¿Estaría disponible con poca aviso para entradas a eventos especiales (eventos deportivos, conciertos, etc.)?
*
Yes
No
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Statistical Information / Información Estadística
This information is collected ONLY for statistical purposes and will not affect services provided. CCFSC does not engage in discrimination against any person on the basis of race, color, national origin, religion, sex, ancestry, or sexual orientation. CCFSC maintains confidentiality on all patient and family information. / Esta información se colecta ÚNICAMENTE con fines estadísticos y no afectará los servicios proveeidos. CCFSC no discrimina en contra ninguna persona en base a raza, color, nacionalidad, religión, sexo, linaje, ni orientación sexual. CCFSC mantiene toda informaciónde paciente/familia confidencial.
Race (Select all that apply) / Raza (Seleccione todas las que correspondan)
American Indian/Alaskan Native
Hispanic/Latino
Black/African American
Asian or Pacific Islander
White
Other
Combined yearly income for your household / Ingresos anuales combinados para su hogar:
Please Select
$0 - $23,999
$24,000 - $37,300
$37,301 - $42,649
$42,650 - $47,949
$47,950 - $53,299
$53,300 - $57,549
$57,550 - $61,849
$61,850 - $66,099
$66,100 - $70,349
$70,350 +
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Parent/Guardian Signature / Firma de Padres o Guardián Legal
*
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: