DATE
PARENT / GUARDIAN NAME
ADDRESS
CITY , NH. ZIP
PHONE
E-MAIL ADDRESS
CHILD'S NAME
CHILD'S GENDER  CHOOSE GENDER MALE FEMALE
BIRTHDATE
CURRENT GRADE IN SCHOOL
DIAGNOSIS
DATE OF DIAGNOSIS
TREATMENT CENTER
NH MEDICAID STATUS CHOOSE STATUS Open or Active Pending Application Do Not Have Never Applied
PHYSICIAN'S NAME
PHYSICIAN'S PHONE NUMBER
IS YOUR CHILD RECEIVING ONGOING MEDICAL TREATMENT? Yes No
IF YES, BRIEFLY DESCRIBE:

SIBLINGS BIRTHDATES
                                         
                                         

SERVICES

Would you like to be on our mailing list? Yes No
Would you like to receive grocery certificates? Yes No
If YES, please select the major grocery store most conveniently located for you Select One Shaws Hannaford Market Basket / Demoulas
Would you be interested in receiving meal vouchers for your treatment center cafeteria? Yes No
Would you like to receive a prepaid phone card? Yes No

The CHILDHOOD CANCER LIFELINE would like to thank you for taking the time to fill out this application. It is our hope that while your child is going through treatment, and afterwards,
you will let us be your lifeline.....

Please feel free to call or email us if we can be of any assistance!