SUPPORTING OUR CANCER KIDS (S.O.C.K.)
Supporting Our Cancer Kids (S.O.C.K.)
P.O. Box 2282
Vacaville, CA 95696
www.sockcancer.org
707.646.1765

NEW FAMILY QUESTIONNAIRE
We would like to welcome you and your family to Supporting Our Cancer Kids (S.O.C.K.). It is our mission at S.O.C.K. to support children diagnosed with cancer and their families. The main purpose of this questionnaire is to gather the information we need to give you, and your family, the support that you need. Please answer all the questions as best as you can. The more information we have about your and your family, the better wen tailor our services to your needs. Your information may help S.O.C.K. receive funding through grants and other opportunities.
The questions on this form marked with an asterisk (*) are for the exclusive purpose of gathering statistics, often requested by grant makers and foundations. Your personal information will never be shared with any person or organization outside of the staff and board of Supporting Our Cancer Kids without your written consent.
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CHILD DIAGNOSED WITH CANCER
Please provide the following information for the child in your family diagnosed with cancer.
NAME
Gender
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Birthdate
MM
/
DD
/
YYYY
Diagnosis
Date of Diagnosis
MM
/
DD
/
YYYY
Treating Hospital
Name of Primary Oncologist
Name of Child's School
Grade Level
Teacher's Name
Child's Favorite Things
What is child's ethnic identity?
What kind of support are you hoping to receive from Supporting Our Cancer Kids?
How did you hear about Supporting Our Cancer Kids?
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