Family Information

Radiation Vacation Foundation, an oasis in the desert, serving families that have a child receiving radiation.
420 Windsor Ct ▪ Macon GA 31216▪ 478-788-8222


In order to best serve your family, please provide the following info and return to the address above, or email the info to For more info about RV you can visit us on facebook or call the number listed above.

Patient Name: ____________________________ 

Date of birth: _______Today’sdate:   ___________

Diagnosis: ________________________________

Date Radiation is scheduled to begin: ________


Place you are staying during Radiation:________________

Parents/Guardian’s Name(s):

1_________________________ 2___________________________

Other care taker’s of your children that you would like included in family events.

1_________________________ 2______________________________

Address: ___________________________________________________

Phone Number: __________________________ 

Email address: _________________________________

Please list names and ages of siblings:

1__________________________ 2_________________________

3__________________________ 4______________________

Do you have a Caringbridge/Carepages/Facebook page for your child? _____________

If so, please give Website Address: ___________________________________________

Can we share this website with Radiation Vacation Supporters? ___________________

What are some of your family’s hobbies/favorite things/activities? _______________________________________________________________________


Is there anything else you would like to tell us about your child or family? _______________________________________________________________________



By signing, I hereby agree that the information provided to Radiation Vacation Foundationis accurate. I authorize RV to use any pictures, video or interview segments of my child/family provided or taken during RV events or fundraisers. I also authorize the use of pictures (of my child/family) that I provide in order to fulfill RV’s mission to raise awareness and to provide support to families.

Parent/Guardian Signature ____________________________________________________ Date________________