About you
I am 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 healthcare institution/organisation *
Your email *
Your telephone number *
Your address *
How did you hear about our wellbeing grant for families? *
Please tell us how you are related to your child or young person *
Has a grant application previously been made by, or on behalf of the family that was successful? *
------
Yes
No
Unsure
Have you previously made an application for a wellbeing grant that was successful? *
------
Yes
No
Unsure
About your child or young person
About the child or young person
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 *
Are they receiving treatment for neuroblastoma? *
------
Yes
No
About your child's Clinical Nurse Specialist
Nurse first name *
Nurse last name *
Their email
Their institution *
About the parent/guardian
Parent/guardian first name *
Parent/guardian last name *
Their email *
Their address *
About the grant
Please tell us how the grant will be used *
Bank details
Account holder name (as it appears on the bank account) *
Bank name *
Account number *
Sort code *
Please confirm how the account holder is related to the child or young person? *
Confirmation of eligibility criteria
Please confirm the family meets the following eligibility criteria:
Confirmation of eligibility criteria
Please confirm your family meets the following eligibility criteria:
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 email
By text
By phone
