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Chemo Angels
P.O. Box 1971
Julian, CA 92036

USA

E-mail us...
 

 

 

 
Patient Sign-up Form for Children

Some of the questions below are gender specific. If they do not apply to the child, skip to the next question. Please keep in mind that the more information we have, the better.  We do not accept children under 24 months of age into our program because younger children are not able to reap the full benefits of our service. Applicants 17 years or older, please fill out an adult application. Please do not sign up a child without the parent/guardian's full knowledge and consent.

Child's Full Name:
Nickname/Goes By:
Home Address:
City, State, Zip:
Country:
   
Telephone No:  
Parents E-mail address:  
   
Birthday:
Age:
Gender: girl   boy
   
  If child is currently living in a hospital, residential facility, or is living away from home for treatment, indicate child's  complete current postal address below.
Facility name, if any
Current postal address:
Current city, state, zip
   
child's  website address, if any
   
Date treatment starts/started:
   
Estimated end of treatment date:
   
Type of treatmt - IV chemo,  oral chemo, radiation, surgery, etc...
   
Type of cancer:
   
Stage of cancer:
  Note for ALL leukemia patients! Due to it's lengthy treatment, we are able to accept ALL (acute lymphoblastic leukemia) patients for one year, if they are in the first year of treatment.
   
Any other relevant health information
   
Provide Name & Phone # of child's Oncologist   

we verify all applicants through their oncologists.
   
How did you hear about Chemo Angels:  
   
Briefly tell us about child and describe the Hobbies/Activities he/she  enjoys:
   
Tell us about child's favorite (mailable) snacks and treats:
   
Does child have any dietary restrictions or allergies:
   
What is child's favorite color:
   
What kind of music does child like:
   
What books/magazines does child enjoy:
   
What is child's favorite animal or animals:
   
What is child's favorite sport:
   
What is child's favorite team:
   
What is child's favorite cartoons:
   
What is child's favorite TV show:
   
Does child have any pets?
   
What is child's clothing size?
   

Does child like to draw/paint?   yes   no           If yes, do you like to draw/paint with   coloring books   blank paper   crayons   markers   colored pencils   brushes   other...

Does child like:   stickers   teddy bears   butterflies   angels   action figures   smiley-face stuff   bracelets   necklaces   temporary tattooes   nail polish   skateboards   dinosaurs   beanie babies   hats/headwear   dolls   hearts   other...

Does child like books?   yes   no     If yes, what is your reading level...

Tell us about the books child likes to read:

 popular age-appropriate fiction     young adult romance    biographies   non-fiction   comedy/humor   scary   comics   action/adventure   children's classics   history   sports    mysteries      science fiction/fantasy  

other...

Does child prefer...   VHS (video tapes) or DVD's?   VHS   DVDs      Cassette tapes or CD's?   cassettes   CDs

Does child like   word puzzles   mazes

Does child like   bubble baths   scented soaps   sprays    

If yes to any, indicate your scent preference   fruity   floral   fresh   earthy

Use the following box to indicate anything else you can think of... things child  likes to do, collect, construct, favorite toys, anything that cheers child up, etc:

 

Does child celebrate:   Christmas   Hanukah   Halloween  

If religion is important in your family life, please tell us about it:

...if you do not wish child to receive any religious oriented notes or gift items, please indicate here  

 

Does child have siblings under the age of 16? If so, indicate their names, genders, ages, birthdays and interests in the box below:

Parental Information. List parents full names in the box below:

Parents e-mail address:  

If there is anything else at all you can think of...please indicate in the following text box. Any further information you can give us as to child's likes and/or dislikes would be greatly appreciated by our program. Thank you!

 

Check-Ins
Your only obligation as a recipient of our program is to respond to the check-ins that we will send you each month. Your regular monthly feedback is vital to the success of our program. If we do not hear from you in response to a monthly check-in, we will try to get in touch with your contact person. If we are unable to reach both you and your contact person for more than two consecutive months, we will have to remove child from the program.   yes, I understand the importance of responding to the monthly check-ins in a timely and informative manner, and will do my best to comply.

 

Emergency Contact Person other than a parent
Chemo Angels administration needs a emergency contact person, a close friend or relative over the age of 21 who generally knows what is going on in child's life. This person will only be contacted if we are unable to reach the child's  parents. He or she must have an e-mail address other than yours, must be 21 years or older, and have a postal and email address other than yours. This person must be someone other than the child's parents.
Contact Persons Name:
   
Contact Persons e-mail address:  
   
Contact Persons mailing address:
   
Relationship to applicant:
   

 

There are times when some extra attention and encouragement may be helpful. During such a time we have "Special Assignment Angels" who send cards, letters of support, and perhaps a small gift to those in need of some extra encouragement. If you do not wish to have your address given to the Special Assignment Angels at any time, please indicate so below. Regardless of which option you choose, your address and information will never be given to anyone outside of our organization.

yes, if needed, this child can be a recipient of a Special Assignment

no Special Assignment please. Only give out my address to my assigned Angel.

 

If you are signing up someone else child, please give the following information. Thank you!

Your name:
   
Your e-mail address:
   
Your relationship to applicant:
   

 

 

 

 

 

  
 
   

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