About you
I am a making an application *
----
For my family as a parent/guardian
On behalf of a family
I am a *
----
Social Worker
Clinical Nurse Specialist
Other
Your title *
----
Mr
Mrs
Miss
Ms
Dr
Professor
Other
Your first name *
Your last name *
Your email *
Your telephone number *
Your address *
Please tell us how you are related to your child or young person *
Your healthcare institution/organisation *
How did you hear about our Family Support Bags? *
About the child or young person in active treatment
Child or young person's first name *
Child or young person's last name *
Their gender *
Their date of birth *
Their treating centre *
Their staging of disease at diagnosis *
----
Low-risk
Intermediate-risk
High-risk
Their date of diagnosis *
About the parent/guardian
About your child or young person’s Clinical Nurse Specialist
Nurse first name *
Nurse last name *
Their institution *
Parent/guardian first name *
Parent/guardian last name *
Their email *
Their address *
About the Family Support Bag
What is your child or young person’s preferred name for the bespoke print? *
What is the child or young person’s preferred name for the bespoke print? *
What colour would they like the preferred name to be printed in? *
----
Pink
Blue
Confirmation of eligibility criteria
Please confirm your family meets the following eligibility criteria:
Confirmation of eligibility criteria
Please confirm the family meets the following eligibility criteria:
My child or young person is in active treatment for neuroblastoma
*
My family has not already received a Family Support Bag
*
Their child/young person is in active treatment for neuroblastoma
*
The family has not already received a Family Support Bag
*
Declarations
Please read and agree to the following statements:
Can we keep in touch with you?
We will tell you about how we’re driving change for families affected by neuroblastoma through our research, support, and awareness work as well as about different fundraising events and initiatives including our children’s campaigns for access to treatment. We will always keep your details safe and will never share them with other organisations for their own marketing purposes. You can change your preferences or opt-out of communications at any time by using the unsubscribe link in our emails or by contacting us at info@solvingkidscancer.org.uk.
By phone
By text
By email
