Warrior (Age Newborn to 5 yrs) Sign Up Form
Patient's Name:
Patient's Street Address:
City, State:
Zip Code:
Patient's Birthdate:
Patient's Diagnosis:
Date of Original Diagnosis:
Estimated Off Treatment Date:
* (An estimated date MUST be included or child is automatically denied)
Oncologist's First & Last Name:
Oncologist's Address & Phone:
Please Let Us Know If Child
Has Any Handicaps, Allergies:
Parent/Guardian's Name:
Parent/Guardian's Phone:
Parent/Guardian's Email
Address:
Note:  Email is our main form of communication.  Applications submitted without
a valid email address will be automatically denied.
TELL US ABOUT THE CHILD WARRIOR
Shirt Size:
Pant Size:
Shoe Size:
Diaper Size:
Child's Favorite Type Toys:
Child's Favorite Snacks:
Child's Favorite Cartoon
Characters/Super Heroes/
TV Shows:
Does Child Have A VCR?
Yes, we have a VCR
No, We don't have a VCR
Does Child Have A DVD?
Yes, We have a DVD
No, We don't have a DVD
Child's Website Address:
Please list any special places or activities your family enjoys doing together
when child is not hospitalized?
Please list child's favorite activities, hobbies, etc., or anything else you'd like us
to know about your child:
Warrior Child's Family
Sibling #1:  List Name, Age, Favorite Hobbies, Foods, Activities, Shows,
Characters, TV Personalities, Sports, etc:
Sibling #2:  List Name, Age, Favorite Hobbies, Foods, Activities, Shows,
Characters, TV Personalities, Sports, etc:
Sibling #3:  List Name, Age, Favorite Hobbies, Foods, Activities, Shows,
Characters, TV Personalities, Sports, etc:
Please check this box if you wish your child's picture and FIRST
NAME ONLY to be listed on our Meet Our Warriors page or other
awareness publications? (Otherwise, leave blank)
Please tell us how you
heard about us!
By submitting this form, you are requesting your child to be a part of Cancer
Warriors and agree that all the personal information you have provided for
the child is true and correct.  Any false information provided will be
punishable at the highest extent of the law.  We have the right to verify all
information provided and exercise this right.  Thank you for allowing your
child to be a part of our Organization.  Either party can cancel participation at
any time.  
Parent/Guardian Signature:
Note: Cancer Warriors considers a typed name a valid signature.
TODAY'S DATE:
Thank you for your interest in signing up your Warrior child with Cancer
Warriors, Inc.  

Every new “Warrior” receives a “Warrior Angel” and “Christmas Angel"
while receiving chemotherapy and/or radiation treatment for cancer.  The
“Warrior” child is considered a part of the Cancer Warriors family until
he/she is considered "off treatment" or receives a transplant.  

PLEASE NOTE: Christmas Angels are only assigned upon having enough
volunteers so we cannot guarantee this will be possible each year but
certainly do our best to make this happen every single year.  

We are excited to have you as a part of our growing family and pray your
time with us will be a positive experience. All registered children will be
required to have a form signed by his/her oncologist before becoming
ACTIVE.  The form will be mailed immediately to the address provided on the
form below.  We need as much information as possible to be able to assign
your child the best possible Warrior Angel.  

Please answer the following questions:   
Cancer Warriors, Inc.
Help For Children Battling Cancer
"Because Kids Get Cancer Too!"