Family Registration

If you have any questions, please email [email protected] or call 904-543-2610.

Eligibility Guidelines
Our focus is children and young adults, ages 0-22 years old, currently undergoing treatment or up to 6 months following treatment.

The child must be a permanent resident of one of the following:
North Florida – Alachua, Baker, Bradford, Clay, Columbia, Duval, Flagler, Nassau, Putnam, St. Johns, or Union County
South Georgia – Camden, Charlton, Clinch, Glynn, or Ware County
Northern NJ – Bergen, Essex, Hudson, Middlesex, Passaic, or Union County
New York City – Bronx, Brooklyn, Manhattan, Staten Island, or Queens
Parent/Guardian information:
Parent's Name*
Prefix First Last
Spouse/Partner's Name
Prefix First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
County*
Email*
Phone*
Patient Information:
Patient's Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Patient's cancer diagnosis:*
Patient's Date of Diagnosis:*
MM slash DD slash YYYY
Hospital/Treatment Facility Name:*
Sibling Information:
Sibling (1) Name:
First Last
Sibling (1) Date of Birth:
MM slash DD slash YYYY
Sibling (2) Name:
First Last
Sibling (2) Date of Birth:
MM slash DD slash YYYY
Sibling (3) Name:
First Last
Sibling (3) Date of Birth:
MM slash DD slash YYYY
Sibling (4) Name:
First Last
Sibling (4) Date of Birth:
MM slash DD slash YYYY
Sibling (5) Name:
First Last
Sibling (5) Date of Birth:
MM slash DD slash YYYY
Additional Siblings' Names and Dates of Birth:

Eligibility Guidelines