In order to best serve your family, please provide the following info and return to the address above, or email the info to firstname.lastname@example.org. For more info about RV you can visit us on facebook or call the number listed above.
Patient Name: ____________________________
Date of birth: _______Today’sdate: ___________
Date Radiation is scheduled to begin: ________
Place you are staying during Radiation:________________
Other care taker’s of your children that you would like included in family events.
Phone Number: __________________________
Email address: _________________________________
Please list names and ages of siblings:
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________________