Fostership Care Package Intake Form

Please make sure to click "DONE" at the bottom of the survey to submit.

Question Title

1. Parent/Guardian of Child Contact Information (Required.)

Name *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country

Email Address *

Phone Number *

Question Title

2. Contact Information (if not the parent or guardian making referral)

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

Question Title

3. Child's Date of Diagnosis (Required.)

Date / Time

Date

Question Title

4. Diagnosis of Child (Required.)

Question Title

5. Hospital of Treatment (Required.)

Question Title

6. Child on Treatment Information (Required.)

Baby (Boy) - less than 2 years old

Baby (Girl) - less than 2 years old

Toddler (Boy) - 2 to 4 years old

Toddler (Girl) - 2 - 4 years old

Child (Boy) - 5 to 8 years old

Child (Girl) - 5 to 8 years old

Tween (Boy) - 9 to 12 years old

Tween (Girl) - 9 to 12 years old

Teen (Boy) - 13+ years old

Teen (Girl) - 13+ years old

Question Title

7. I authorize Fostership to contact me. (Required.)

Yes

Question Title

8. I authorize Fostership to share my information with Kids Cancer Care Foundation of Alberta who is affiliated with Fostership. (Required.)

Yes

Question Title

9. How did you hear about Fostership? (Required.)

Hospital

Internet search

Social Media

Social Worker

Friend or Family

Another family with a child diagnosed with cancer

Other (please specify)

Fostership Care Package Intake Form

Please make sure to click "DONE" at the bottom of the survey to submit.

Question Title

* 1. Parent/Guardian of Child Contact Information (Required.)

Question Title

* 2. Contact Information (if not the parent or guardian making referral)

Question Title

* 3. Child's Date of Diagnosis (Required.)

Question Title

* 4. Diagnosis of Child (Required.)

Question Title

* 5. Hospital of Treatment (Required.)

Question Title

* 6. Child on Treatment Information (Required.)

Question Title

* 7. I authorize Fostership to contact me. (Required.)

Question Title

* 8. I authorize Fostership to share my information with Kids Cancer Care Foundation of Alberta who is affiliated with Fostership. (Required.)

Question Title

* 9. How did you hear about Fostership? (Required.)

1. Parent/Guardian of Child Contact Information (Required.)

2. Contact Information (if not the parent or guardian making referral)

3. Child's Date of Diagnosis (Required.)

4. Diagnosis of Child (Required.)

5. Hospital of Treatment (Required.)

6. Child on Treatment Information (Required.)

7. I authorize Fostership to contact me. (Required.)

8. I authorize Fostership to share my information with Kids Cancer Care Foundation of Alberta who is affiliated with Fostership. (Required.)

9. How did you hear about Fostership? (Required.)