Family Information Questionnaire

Child Information

Child’s Name:

Child’s Age:

Child’s Date of Birth:

Child’s Gender
FemaleMale

Is the child actively receiving treatment?
YesNo
If no, when did your child last receive treatment?

Child’s Diagnosis & Date of Diagnosis:

Is your child’s treatment being facilitated at a hospital?
YesNo
If yes, which hospital?

Please attach a physician’s form.

Social Worker Name, Email, and Phone Number:

Can the child be around groups of people?
YesNo

Does your child have any physical restrictions?
YesNo
If yes, please describe (e.g., cannot be outdoors, require wheelchair accessibility, amputee, etc.):

Family Information

Household Size

How many people currently live in your household?
12345+

Does the child have siblings?
YesNo
Please list the name and age of each family member:

Parent’s Information

Parent/Guardian Name(s)

Parent’s email

Parent’s phone

Parents complete mailing address

Parent’s social media account URLs

[acceptance* acceptance-21 optional] I give permission to be contacted about Leia’s Kids by SMS text at my residential or cellular number or provided email address, dialed manually or by autodialer (consent to be contacted is not a condition to participate) and to be contacted via email. I consent to be contacted even if my phone number or email address appears on a Leia’s Kids Do Not Call / Do Not Email List, a State or National Do Not Call Registry, or any other Do Not Contact List. [/acceptance]

Party & Celebration Details

What would be your child’s ideal party theme? (We cannot guarantee a specific theme but will do our best! e.g., superheroes, princesses, sports, animals, etc.)

Top Two Favorite Princesses (if applicable):

Top Two Favorite Superheroes:

Top Two Favorite Sports Teams:

Top Two Favorite Animals:

What are your child’s favorite colors?

What are your child’s favorite activities or hobbies?

Parties are for immediate family members only. By request only, can we extend the invite list.

How many people do you plan to have present?

Are there any food allergies or dietary restrictions we should be aware of?

Will this party be used for: (Check all that apply)
Birthday CelebrationEnd of Treatment CelebrationRinging the BellA Party to Celebrate & Have FunA Pick-Me-Up for the FamilyDecor to decorate the hospital room

Does your family prefer:
Overnight stay at Great Wolf Lodge (or similar venues)An at-home party with a characterSupplies shipped to your home to match the themeTickets to a sports game or theme parkA donation to supply the dream partyA child or family photoshootA shopping experience (American Girl, Dicks etc)

Family’s Cancer Journey

What has been your biggest challenge and need in fighting against childhood cancer?

What is your family’s greatest need at this time?

How has this journey impacted your family’s daily life?

Nomination & Verification

How did you hear about Leia’s Kids?

Please upload a picture of your warrior here:

[acceptance* acceptance-995 optional] By checking this box, I give my permission for Leia’s Kids Foundation and/or its representatives to use artwork, photographs and/or letters/the story that I provide of my child, my family, and/or myself in publications, slides, videotapes, motion pictures and/or on the Internet. In addition, I hereby give my permission for Leia’s Kids and/or its representatives to photograph, audio tape record, and/or videotape my child or myself and to use our names, these images or voice recordings in publications, slides, videotapes, motion pictures and/or on the internet. I understand these visual images or voice recordings may be used to inform families, volunteers, donors, the media and general public about Leia’s Kids programs, services or events. I gladly give this authorization to support the efforts of Leia’s Kids. I understand this authorization shall continue until terminated in writing. Providing consent is not a requirement in order to participate in Leia’s Kids programs. [/acceptance]

Confidentiality Statement

Your responses to the following questions will not disqualify you from receiving assistance. This information is collected solely for data collection and program expansion purposes. All responses will remain confidential and will not impact your eligibility for assistance.

Household & Financial Information

Household Income

What is your estimated annual household income??
Under $25,000$25,000 – $49,999$50,000 – $74,999$75,000 – $99,999$100,000 – $149,999$150,000+
Estimated Household Income After Diagnosis:

Additional Financial Burdens

Are there other medical needs in your household? (For example, another child undergoing treatment, a family member with a chronic illness, disabilities, neurological conditions such as epilepsy, or any other medically complex needs.)

Are there other financial burdens you would like to share? (e.g., a child in college, single-family income, other major expenses)

Financial Impact of Cancer

Has a cancer diagnosis impacted your household financially?
If so, please describe how (e.g., loss of income, increased medical expenses, caregiving responsibilities, etc.):

Has a parent/caregiver stopped working or reduced hours due to your child’s illness?
YesNoReduced Hours

Financial Challenges

Have you faced any of the following financial struggles due to your child’s illness? (Check all that apply)
Difficulty paying rent/mortgageUtility shutoff noticesCar payments or transportation issuesMedical debtBankruptcyEviction riskOther
If Other, specify here: