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
State/ Province / Region
Postal/ Zip Code
Country


Second Parent / Guardian Information

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


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?*
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