Self-Referral Form for Families Interested in Side-by-Side Volunteers
Side-by-Side Family Support matches teams of two screened, trained, and supported volunteers to families who have temporarily relocated to Seattle for treatment of the serious illness of a child or a parent. Our purpose is to provide safe and fun play and friendship for your child(ren) once a week while active treatment in ongoing. Volunteers can be with patients and or siblings at Seattle Children's Hospital, the Ronald McDonald House and other local housing locations, as well as all around Seattle on outings and adventures.
Today's date:
MM
/
DD
/
YYYY
Family Information
Parent and or Caregiver #1, name and relationship to patient
Your answer
Parent and or Caregiver #2, name and relationship to patient
Your answer
Parent and or Caregiver #3, name and relationship to patient
Your answer
Parent and or Caregiver #1's marital status
Your answer
Primary Language spoken by family
History of drug/alcohol abuse?
History of violence?
Patient's full name
Your answer
Patient's age and gender
Your answer
Diagnosis
Your answer
Date of diagnosis (approximate is fine)
MM
/
DD
/
YYYY
Estimated length of support (example: 4 months)
Your answer
Names, ages, and genders of other children with family in Seattle
Your answer
Family Contact Information
Seattle Residence (RMH, Pete Gross House, apartment or house rental, etc.)
Your answer
Parent and or Caregiver #1's cell phone number and email
Your answer
Family's previous residence (city, state)
Your answer
Description of Volunteer Support Requested
Family Needs
Anything else we should know about your family?
Your answer
Specific type of volunteers requested (age, gender, personality, experience):
Your answer
All information submitted is solely for the use of Side-by-Side and will be kept confidential. Thanks for your referral--we will be in touch very soon!
Submit
Never submit passwords through Google Forms.
This form was created inside of Side-by-Side. Report Abuse - Terms of Service - Additional Terms