The Izzy Foundation Family Membership Form
The information will be kept confidential unless you choose to be part of our "patient spotlight" program. If you have any questions or concerns please email us at erin@theizzyfoundation.org or call us at 401-636-2434. Thank you - Erin Scott
Parent #1 First Name and Last Name
Your answer
Parent #1 First Name and Last Name
Your answer
Patient's First and Last Name
Your answer
Patient's birthdate and age:
Your answer
Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
Phone number
Your answer
Email address:
Your answer
Website or Facebook page:
Your answer
Diagnosis (type):
Your answer
Date of diagnosis and length of treatment:
Your answer
My child is:
What is your child's treatment story? (Please only share what you are comfortable with)
Your answer
Would you be interested in being involved in our "patient spotlight" program and share your child's picture and story on our website, newsletter or social media page?:
Do you have other children? If yes, please list their names and ages:
Your answer
Have you used the Izzy Family Room?
If you answered yes, what was the best part of the room?
Your answer
If you answered yes, how could we improve the room?
Your answer
Would you like to receive our monthly e-newsletter?
Would you be interested in volunteering with The Izzy Foundation? If yes, please choose any of the following.
If not listed, please list in any other ways you would like to volunteer:
Your answer
Do you know of a company or individual that might want to donate an auction item for our gala, attend the gala or be interested in corporate sponsorship? If so, please list name, address and phone number. Thank you.
Your answer
Is there anything else you would like to share with us? THANK YOU for participating!
Your answer
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