PLEASE PRINT

PARENTS [ ] GUARDIANS [ ] (Please check one)

Mother:

Last _________________________________________ First ___________________________________

Mailing Address________________________________________________________________________

City ___________________________________ Zip_________________ Island ___________________

Home Phone ______________________________ Business Phone ______________________________

Father:

Last ________________________________________ First ____________________________________

Mailing Address________________________________________________________________________

City ___________________________________ Zip_________________ Island ___________________

Home Phone ___________________________________ Business Phone _________________________

CHILDREN IN HOUSEHOLD

Last Name First Sex Date of Birth

* (Patient) ___________________________ _________________ ________ _________________

___________________________ _________________ ________ _________________

(If you need more space, please continue on back)

Child’s (*Patient) Diagnosis_____________________________________________________________________

Treating Physician’s Name______________________________________________________________________

Treating Facility_______________________________________________________________________________

Date Diagnosed Mo.__________ Year __________

[ ] Currently in Treatment [ ] Treatment Completed [ ] Treatment Completed

> 5 years

I am interested in the following:

[ ] Financial/Travel Assistance

[ ] Parent to Parent Support

[ ] Children’s/Siblings Groups

[ ] Getting support/special help for child to succeed in school

[ ] Information on child’s diagnosis

[ ] Long term follow-up care

[ ] Candlelighters (national childhood cancer organization)

[ ] Volunteering for HCCF

[ ] Other ____________________________________________________________

How did you hear about HCCF?

[ ] Other parents/family [ ] Physician [ ] Nursing Staff

[ ] Social Worker [ ] HCCF Newsletter [ ] HCCF Website

[ ] Other __________________________________________________________________

You will automatically be enrolled as an HCCF member (there is no fee)

and added to our mailing list for all activities & events.

Signature ________________________________________________ Date_______________

TO REQUEST SERVICES OR INFORMATION, PLEASE CALL:

OAHU 808-528-5161

NEIGHBOR ISLANDS TOLL-FREE 1-866-443-HCCF (4223)

Please mail this form to:

Hawaii Children’s Cancer Foundation

1814 Liliha Street

Honolulu, HI 96817