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Patient's Name:
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Street Address (PO
Box preferred):
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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
Address:
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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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Teen's Favorite Music Group(s):
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Teen's Website providing
updates on progress:
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Teen's Favorite Color(s):
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Teen's Favorite Snacks:
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Teen's Favorite TV
Personalities/Shows:
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Does Teen 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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Please list any special places or activities your teen/family enjoys doing in spare time or when
teen is not hospitalized?
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Please list teen's favorite activities, hobbies, etc., or anything else you'd like us to know about
him/her:
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Please list Teen's favorite Sport teams, college teams, etc.:
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If Teen enjoys reading, favorite authors or type of books he/she enjoys
(including magazines or comics):
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Please list Teens favorite 3 stores:
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Please list families closest grocery store:
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Does Teen collect anything? If so, please list items he/she collects:
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Teen's favorite movies titles or type movies to watch:
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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 if you wish your child's picture and FIRST NAME ONLY to be listed
on our upcoming childhood cancer awareness video for our website and possibly
U-tube, as well as awareness brochures, etc. You MUST submit a photo to us if the teen
does not have a website to be included in this upcoming project.
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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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