SSTTR Family Registration & Update Form
New families: please complete the following registration form to join the Second Star to the Right organization.
Renewal families: please complete the form below to ensure we have up-to-date information about your family and to continue your membership within the SSTTR organization.
You may contact Brianna Schechter or David Tate with any questions.
Email address *
Family & Contact Information
Parent / Guardian's first and last name completing this form *
Your answer
Spouse's first and last name
Your answer
Best contact phone number *
Your answer
Home Address *
Your answer
Primary Language? *
Sibling names and their ages (if none type "none") *
Your answer
Pediatric Cancer Patient Info
Patient name (include last name if different from yours): *
Your answer
Date of birth *
MM
/
DD
/
YYYY
Diagnosis *
Your answer
Patient age at diagnosis *
Your answer
Date of diagnosis *
MM
/
DD
/
YYYY
Current treatment facility: *
If "other" please tell us what hospital?
Your answer
Treatment status: *
If currently in treatment: expected date of completion:
MM
/
DD
/
YYYY
If currently in treatment: type and how often are you going for treatment?
ie outpatient radiation once a week, in-patient chemo twice a month etc.
Your answer
Round trip mileage from home to treatment facility: *
Your answer
Means of travel for treatment *
Overnight Stays: *
Yes
No
Are overnight stays required for treatment?
If yes, are they provided free or at little cost from the treatment facility or family housing unit?
Please let us know any other information you feel is important that we should know about your family. i.e. Immediate family needs. Special circumstances. Ways you want to help out with SSTTR. Suggestions etc.
Your answer
Social Worker information (if applicable)
Name of Social Worker
Your answer
Email address of Social Worker
Your answer
Phone number of Social Worker
Your answer
Consent questions:
By typing my name below I certify that the information in this form is TRUE and CORRECT to the best of my knowledge. I also release Second Star to the Right and any of their volunteers, board members or community partners of any liability that may be incurred by participating in Second Star to the Right activities: *
Your answer
If chosen for one of Second Star to the Right's family grants I agree to provide the following: *
I agree
I disagree
A medical document stating the child’s name and diagnosis.
A bill or other document confirming the family’s current address & amount requested.
By clicking "I agree" I consent to the exchange of personal and/or medical information between Second Star to the Right and medical facilities and their staff to facilitate services provided by Second Star to the Right: *
Required
Media release: by clicking "I agree", I consent to the use of my child’s basic info (first name, age, diagnosis) and pictures on our literature, website and or social media? *
Required
Congratulations! If you are a new here, welcome to the Second Star to the Right family. We look forward to meeting you soon. For returning families, thank you for your continued membership within the Second Star to the Right organization, we appreciate your love and support. *Don't forget to click "submit".
Submit
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