Empower Packs

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?*




EmPower Pack Tablet*:

Foundation note: the tablet is now optional to maximize the amount of support we can provide to newly diagnosed children.

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