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Thank you for your interest in signing up your Warrior child with Cancer Warriors, Inc.
GEORGIA RESIDENTS ONLY!!!!!
Every new “Warrior” accepted into Cancer Warriors receives a “Warrior Angel” and “Christmas Angel" while
receiving chemotherapy and/or radiation treatment for cancer. The “Warrior” child is considered a part of the
Cancer Warriors family until he/she is considered "off treatment" or receives a transplant.
PLEASE NOTE: Christmas Angels are only assigned upon having enough volunteers so we cannot guarantee this
will be possible each year but certainly do our best to make this happen every single year.
Cancer Warriors criteria: Our mission is to outreach to the families in Georgia who have a child on treatment for
cancer, and are struggling financially. All applications will be reviewed and must be approved by a social worker.
We have the right to verify all families to be sure they meet our criteria so we don't take away from other families in
need. We normally have one of our volunteers contact you to set up a date/time to sit down with your family to
assess your needs. Every family has different needs and this helps us provide the best outreach possible.
Please answer the following questions:
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Patient's Name:
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Patient's Street Address:
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City, State:
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Zip Code:
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Patient's Birthdate:
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Patient's Diagnosis:
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Date of Original Diagnosis:
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Estimated Off Treatment Date:
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* (An estimated date MUST be included or child is automatically denied)
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Oncologist's First & Last Name:
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Oncologist's Address & Phone:
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Please Let Us Know If Child Has Any Handicaps, Allergies:
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Parent/Guardian's Name:
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Parent/Guardian's Phone:
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Parent/Guardian's Email:
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Note: Email is our main form of communication. Applications submitted without a valid email address will be automatically denied.
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TELL US ABOUT THE CHILD WARRIOR
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Shirt Size:
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Shoe Size:
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Child's Favorite Type Toys:
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Child's Favorite Snacks/Foods/Restaurants:
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Child's Favorite Cartoon Characters/Super Heroes/ TV Shows:
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Does Child Have A VCR?
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Yes, we have a VCR
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No, We don't have a VCR
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Does Child Have A DVD?
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Yes, We have a DVD
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No, We don't have a DVD
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Child's Website Address:
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Please list any special places or activities your family enjoys doing together when child is not hospitalized?
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Please list child's favorite sports, hobbies, etc., or anything else your child enjoys that has not been listed, or anything else you'd like us to know
about your child:
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Warrior Child's Family
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Sibling #1: List Name, Age, Favorite Hobbies, Foods, Activities, Shows, Characters, TV Personalities, Sports, etc:
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Sibling #2: List Name, Age, Favorite Hobbies, Foods, Activities, Shows, Characters, TV Personalities, Sports, etc:
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Sibling #3: List Name, Age, Favorite Hobbies, Foods, Activities, Shows, Characters, TV Personalities, Sports, etc:
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Please tell us how you heard about us!
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Please check this box only if you wish for us to use your child's picture (you must have
provided a website or email a picture for us to use). Only FIRST NAME will be used in our
upcoming awareness video or any other awareness material we may produce. (Leave
blank if you do not wish your child's picture to be used). You must email us a picture if
your child does not have a website listed on this form.
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By submitting this form, you are requesting your child to be a part of Cancer Warriors and agree that all the personal information you have provided
for the child is true and correct. Any false information provided will be punishable at the highest extent of the law. We have the right to verify all
information provided and exercise this right. Thank you for allowing your child to be a part of our Organization. Either party can cancel participation
at any time. Cancer Warriors cannot guarantee every child will be accepted into our program for assistance. We base our acceptance on helping
the most financially needy families first and foremost. Thank you for your understanding!!!!
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Parent/Guardian Signature:
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Note: Cancer Warriors considers a typed name a valid signature.
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TODAY'S DATE:
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