APPLICATION FOR FAMILY SERVICES
To apply for family services you must be a New Hampshire Resident.
This is available for children birth to age 19.

DATE____________

PARENT / GUARDIAN____________________________PHONE(____)______________
ADDRESS_______________________________________________________________
E-MAIL ADDRESS (IF ANY)_________________________________________________

CHILD'S NAME__________________________ CHILD'S GENDER__________________
BIRTHDATE_____________________________ CURRENT GRADE IN SCHOOL______
DIAGNOSIS______________________________ DATE OF DIAGNOSIS_____________
TREATMENT CENTER_____________________________________________________
PHYSICIAN'S NAME AND 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 one of the major grocery store most conveniently located for you:
     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 us if we can be of any assistance!