Shining Stars Health and Social History Form

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To begin the application process, please fill out the form below. Decisions are made on a case by case basis and dependent on if spaces are available. We do our best to serve every family in need who meets our requirements.

Who is Eligible? Children and young adults who are battling cancer or another life-threatening illness and their immediate family. Currently, we provide services primarily to families in Colorado. Other geographic regions served include: Arizona, Illinois, Oklahoma, Virginia, and Indiana.

Application: Please fill out the form below. A staff member will then be in touch to confirm it was received.

Questions or concerns? Email: Office@ShiningStarsFoundation.org

Email *

Parent/Guardian Name(s) *

Parent/Guardian cell phone number(s) *

Parent/Guardian email address *

Mailing Address *

Your City, State and Zip Code *

Parent/Guardian Occupation(s) *

Child's first and last name *

Child's Nickname

Child's Birthdate *

YYYY

Child's Age *

Name of school child attends: *

Name(s) and age(s) of siblings: *

Name of Emergency Contact: *

Relationship: *

Phone Number: *

Health Questions

Child's Diagnosis *

Diagnosis Date *

YYYY

Is your child currently in treatment? *

Yes

Primary Care Physician + Phone Number:

Oncologist Name + Phone Number (if applicable)

Hospital/Clinic where you receive treatment

Brief Treatment History: *

Does anyone in the family have any dietary/allergy restrictions?

Does anyone in the family have any mobility or activity restrictions?

Do you have a website/webpage with updates on your child or family you would like to share with us?

Anything else we should know about your child and family? *

How did you hear about Shining Stars Foundation? *

Submit

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