Riley's Army Triangle Family Registration Form

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Riley's Army Triangle is a 501(c)(3) not-for-profit organization with a mission to support children and families with cancer in the Triangle area. Our services include financial, social, emotional, and spiritual support for children and families on their pediatric cancer journey.

Due to the financial strain of pediatric cancer, each registered Riley's Army Triangle family has up to $2,000 in an emergency fund to be accessed for bills such as rent, utilities, patient needs, car repairs, gas cards, and grocery cards. Up to 12 gas cards per year while in treatment will also be available for each family in addition to the emergency fund. Please note that a 72 Business Hour (Monday- Friday) notice is required in advance for financial support. These inquiries can be sent to our family liaison, Jean Adams, by calling or texting (919) 692-6131 or emailing Ratriangle.familyliaison@gmail.com

Riley's Army is committed to serving our families. We host events for families to interact with hopes that you can find a community to relate to and lean on during your journey with pediatric cancer. Information for these events will be sent out from us via email, text, and/or through your social worker.

It is an honor to serve and know each and every Riley's Army Triangle family. If we can be of any assistance during your journey, please let us know. If it is beyond our capacities, we will try and direct you to someone who can help. Thank you for letting us serve you!

Please fill out the form below so we can add you to our secure, password-protected database. This information is only shared with our family liaison, director, and executive director.

Email *

Patient's Name *

Patient Date of Birth *

YYYY

Please list parent's or caregiver's names, preferred contact method, and addresses. *It is recommended, but not required, that you provide at least one email and phone number. Please note that if you do not provide an email or phone number, you may not receive messages sent out to families regarding events, policies, and updates.*
*

Does the child have any siblings? If so, please list them and their ages.
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Please give a brief description of child's diagnosis including diagnosis date

Are there any additional ways we can help or do you have any questions?
*

By checking the box below, you voluntarily accept help from Riley's Army and know that you can decline services at any time, as you are under no obligation to accept services or share personal information. You acknowledge that services are provided by volunteers and family liaison with approval from the board and understand that there are limitations to such services. You will provide 72 hours notice for financial support requests, and will agree to provide feedback and report any concerns about Riley's Army to the family liaison. You understand that Riley's Army reserves the right to decline services at any time.
*

I have read the information above and agree.

Required

Send me a copy of my responses.

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