Amazing  Adventure


Please fill out the fields below to register with Childhood Cancer Canada.

Parent / Guardian Information

Name *
First*
Last*
 
Email*
Phone number*
Address*
Street*
City*
State/ Province / Region*
Postal/ Zip Code
Country


Parent / Guardian Information

Name
First
Last
 
Email
Phone number
Address
Street
City
State/ Province / Region
Postal/ Zip Code
Country


Cancer Hero's Information

Name*
First
Last
Date of birth*
Gender*
Diagnosis*
Age at diagnosis*
 
Hospital*
Name of Social Worker*
First*
Last*
Siblings (name and age)*


Programs

 
 
How did you hear about Childhood Cancer Canada?*




All About Me

To help us know your child better, please tell us about him/her.
Named

Favourites
Book
Sport
Sports team
Hobby
Colour
Movie
Singer