Youth Inquiry Form
Please fill out the application out as best you can.
What is the child's first and last name? *
Your answer
How old is the child? *
Your answer
What city is the child from? *
Your answer
Are you the parent/guardian? *
What is the parent(s)/guardian(s) first and last name? *
Your answer
What is the best phone number to reach you? *
Your answer
What type of illness does the child have? *
Your answer
Is the child inpatient or outpatient? *
What hospital is the child attending? *
Your answer
What's ahead for the child's treatment? *
Required
What hobbies or interests does the child have? *
Your answer
What's the child's favorite color? *
Your answer
What's the child's favorite music? (genre, song, or artist) *
Your answer
What is the child's favorite TV show? *
Your answer
What is the child's favorite movie? *
Your answer
Does the child have any social media pages? Please add them below if so. *
Your answer
Does the child have any bucket list items? *
Your answer
Please include any additional information about the child or concerns you may have about the process. Please describe where they are from and daily life. If they have siblings/others in the household. When diagnosed, what stage, and what's ahead. What activities and hobbies the child liked to do before diagnosed, and how has the illness affected their ability to enjoy them now? How has the process been thus far? *
Your answer
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