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

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

Date / Time

Date

Question Title

* 4. Diagnosis of Child

Question Title

* 5. Hospital of Treatment

Question Title

* 6. Child on Treatment Information

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.

Yes

Question Title

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

Yes

Question Title

* 9. How did you hear about Fostership?

Hospital

Internet search

Social Media

Social Worker

Friend or Family

Another family with a child diagnosed with cancer

Other (please specify)