Patient & Family Support Form
This form is for CFU staff to use for support and services for pediatric cancer patients and their families. The information collected will help CFU compile data about local childhood cancer statistics as well as creating patient/family stories for awareness and marketing. If you would rather not participate in any awareness or marketing campaigns please indicate your answer in the last question.
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Email *
Child's name     (first/last) *
Birthday (month/day/year) *
Type of Cancer & Diagnosis Date *
Has the child relapsed? *
Tell us about your child. What do they like? What are their dreams? What were they doing before they were diagnosed with cancer? What do they hope to do when their treatment is finished? *
Does the patient have siblings, and how many? Please list immediate family members. *
As part of our family support, CFU is beginning to provide birthday parties for patients in treatment at no cost to the family. Would you be interested in learning more about the CFU birthday program? *
As part of our family support, CFU is adding a new program for patients that have completed treatment at no cost to the family. Would you be interested in learning more about the CFU No More Chemo Celebration program? *
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