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 www.facebook.com/RadiationVacation

 

In order to best serve your family, please provide the following info and return to the address above, or email the info to [email protected]. 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: ________

Hospital:_____________

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________________