Child Information Form

***Please fill out one form for each child in the family planning on participating in any Cancer Support Community activities.

Child's Name(Required)

First Last

Child's Current Age(Required)

Child's Date of Birth(Required)

Name of Parent/Guardian providing information on this child(Required)

Address(Required)

Street Address Address Line 2 City State ZIP / Postal Code

Phone(Required)

Email(Required)

Emergency Contact's Name(Required)

Emergency's Contact Phone(Required)

Who is the person in the family with cancer (or who has died from cancer)(Required)

What is the diagnosis of the person with cancer and when were they diagnosed(Required)

Which adult or adults in your family are members of Cancer Support Community?(Required)

What is your child’s current awareness and understanding of cancer in your family?(Required)

How has cancer affected your child? Have you seen behavioral changes at school, at home with friends and/or siblings?(Required)

Has your child ever received individual counseling or treatment for psychiatric, behavioral, and/or emotional concerns? If so, when?(Required)

If your child is currently seeing an individual counselor, do you think it would be helpful for a staff member to be in contact with them?(Required)

Yes

Not at this time

If yes, a staff member will contact you directly to discuss.

Is your child currently on any medications? If so, please list.(Required)

Does your child have any allergies? If so, please be specific about limitations.(Required)

How do you hope your child will benefit by coming to activities at CSC?(Required)

A staff person will contact you directly to talk more about activities and your child’s participation. Please remember that registration is required for all activities at Cancer Support Community.

Electronic Consent of person filling out form(Required)

Date of Consent(Required)