APPLICATION FOR FAMILY SERVICES

DATE____________

PARENT / GUARDIAN____________________________PHONE(____)______________
ADDRESS_______________________________________________________________
E-MAIL ADDRESS (IF ANY)_________________________________________________

CHILD'S NAME__________________________ CHILD'S GENDER__________________
BIRTHDATE_____________________________
DIAGNOSIS______________________________ DATE OF DIAGNOSIS_____________
TREATMENT CENTER_____________________________________________________
PHYSICIAN'S NAME AND PHONE NUMBER___________________________________
IS YOUR CHILD RECEIVING ONGOING MEDICAL TREATMENT? YES NO
IF YES, BRIEFLY DESCRIBE________________________________________________
_________________________________________________________________________
_________________________________________________________________________

SIBLINGS ___________________ BIRTHDATES____________
                ___________________                     ____________
                ___________________                     ____________

SERVICES

Would you like to be on our mailing list? YES NO

Would you like to receive grocery certificates? YES NO
If YES, please list the major grocery store most conveniently located for you________________

Would you be interested in receiving meal vouchers for your treatment center cafeteria? YES NO

Would you like to receive a prepaid phone card? YES NO

The CHILDHOOD CANCER LIFELINE would like to thank you for taking the time to fill out this application. It is our hope that while your child is going through treatment, and afterwards,
you will let us be your lifeline.....

Please feel free to call us if we can be of any assistance!