Empower Packs

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

Parent / Guardian Information

Name*
First Name
Last Name
 
Email
Phone Number
Street Address*
Street Address
City
Province

Region
Postal Code
Country


Second Parent / Guardian Information

Name
First Name
Last
 
Email
Phone Number
Address*
Street Address
City
Postal Code


Cancer Hero's Information

Name*
First Name
Last Name
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