• Adolescent (Ages 12-18) Member Information

    Please complete this form in its entirety. The information below will be utilized for data purposes only. This information helps our organization to apply for grants to continue funding our operations.
  • (Ex: "he, him"; "she, her"; "they, them")
  • Parent / Guardian Contact Information

  • (Ex: "he, him"; "she, her"; "they, them")
  • Emergency Contact Information

  • Medical Information

    Medical Information for the Individual Diagnosed with Cancer
  • (select all that apply)
  • If you don't know this, please write: "N/A".
  • If the Adolescent is the individual diagnosed with cancer, please write: "N/A".
  • Additional Information

  • Questionnaire (to be completed by Adolescent)

    Please have the Adolescent complete this questionnaire.
  • Program Waiver Agreement

    Please check each box to show that you acknowledge and understand the following statements.
  • Signature of Parent / Guardian