• Child Member Application

    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 Information

  • (Ex: "he, him"; "she, her"; "they, them")
  • Preferred Phone Number for Contact
  • Emergency Contact

  • Medical Information

    Medical Information for the Individual Diagnosed with Cancer
  • If you don't know this, please write "N/A".
  • If the Child is the individual diagnosed with cancer, please write "N/A".
  • Additional Information

  • Program Waiver Agreement

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