Families of Children with Cancer - Family Intake Form
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County of Residence *
Language Preference *
Family Name *
Primary Family Phone Number *
Cancer Child's Full Name *
Cancer Child Date of Birth *
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DD
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YYYY
Child's Diagnosis *
Date of Diagnosis *
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DD
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YYYY
Treating Hospital *
Mom's Full Name
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Mom's Full Address  (include city, state and zip) *
Mom's Phone Number
Mom's E-Mail
Dad's Full Name
Dad's Full Address  (include city, state and zip) *
Dad's Phone Number
Dad's E-mail
If parents are not married, or live separately, please give a short summary of your child’s living and childcare arrangements, whether there are stepparents involved, etc. This information helps us to better support families with services that apply to their unique needs.
Sibling Full Name
Sibling Date of Birth
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DD
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YYYY
Sibling Full Name
Sibling Date of Birth
MM
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DD
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YYYY
Sibling Full Name
Sibling Date of Birth
MM
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DD
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YYYY
Sibling Full Name
Sibling Date of Birth
MM
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DD
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YYYY
Sibling Full Name
Sibling Date of Birth
MM
/
DD
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YYYY
I consent to, and authorize the release of, the above information to the Families of Children with Cancer,Inc., and its representatives. This information can be used for the purpose of providing educational material, newsletters, e- mail correspondence, financial support, and social networking opportunities for families who have children with cancer. In order to provide for easier networking among our families, we have put together a directory for our families to use. This directory provides basic information about the families in our group, so that they may connect with others in similar circumstances. Directories are to be used for group purposes only. Participation is voluntary. *
Required
I do wish to share the above information with the Families of Children with Cancer, Inc., and agree to have it published in a directory to be used exclusively by the Families of Children with Cancer, Inc., as an aid to families who have been affected by childhood cancer. *
Required
I do wish to have my child’s birthday mentioned in the newsletter. *
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