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 *
Spouse's first and last name
Best contact phone number *
Home Address *
Primary Language? *
Sibling names and their ages (if none type "none") *
Pediatric Cancer Patient Info
Patient name (include last name if different from yours): *
Date of birth *
Diagnosis *
Patient age at diagnosis *
Date of diagnosis *
Current treatment facility: *
If "other" please tell us what hospital?
Treatment status: *
If currently in treatment: expected date of completion:
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.
Round trip mileage from home to treatment facility: *
Means of travel for treatment *
Overnight Stays: *
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.
Social Worker information (if applicable)
Name of Social Worker
Email address of Social Worker
Phone number of Social Worker
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: *
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: *
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? *
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".
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