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Childs Name *

First Name

Last Name

Child's Date of Birth *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Ethnicity *

Pediatric cancer does not discriminate nor does KGCT. KGCT complies with applicable federal civil rights laws and does not discriminate based on race, color, national origin, age, disability, religion, or sex. KGCT does not exclude people or treat them differently because of race, color, national origin, age, disability, religion, or sex. In order to apply for grants and/or to receive special funding, it is necessary to collect information concerning ethnicity and race. Your responses below will in no way negatively impact financial assistance. Please check all that apply below.

Hispanic or Latino

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Prefer Not to Say

Social Worker Name

If applicable

First Name

Last Name

Are you a social worker completing this form on behalf of the family? *

Please note that the form will only be accepted when submitted by the assigned social worker or a member of the family.

Yes

No

Story Waiver *

Do you give Kids Get Cancer Too permission to share your child's story and a picture on social media and the KGCT website?

Yes

No