Young Adult ASK Enrollment Form
ASK Childhood Cancer Foundation is a local nonprofit serving families whose children are treated for cancer or other serious blood disorders at the Children's Hospital of Richmond at VCU, as well as young adult cancer survivors who were treated elsewhere but now live in the Greater Richmond (VA) area. Our programs are free of charge for our families, and we never share your information with third parties. By filling out this form, you are consenting to allow us to contact you with offers for our social, educational, psychological, financial, and wellness programs.
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Young Adult's Name *
Date of birth *
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Diagnosis *
Date of diagnosis *
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Treatment center where you are receiving/did receive treatment:
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Address *
Primary language *
Secondary language
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Cell phone # *
May we text your cell phone? *
Email address *
Emergency Contact's name *
Relationship to Emergency Contact *
Emergency Contact cell phone # *
Emergency Contact email address *
Your 1st child's name, if applicable
Your 1st child's date of birth, if applicable
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Your 2nd child's name, if applicable
Your 2nd child's date of birth, if applicable
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Your 3rd child's name, if applicable
Your 3rd child's date of birth, if applicable
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Signature Release: Your signature below provides permission for the release of the above information to the ASK organization. This information will remain confidential and will only be used within the ASK organization. Your signature allows you to be photographed/filmed during ASK social activities and ASK-sponsored community events. These pictures may be used for promotion of ASK through emails, flyers or mailers, and ASK social media. By signing this you are also giving your medical professionals and ASK’s employees, including the Family Support Manager and Young Adult Support Coordinator, permission to share medical information about your case as needed. *
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