Child Information

Child’s Name

Child’s Age

Child’s Date of Birth

Child’s Gender
MaleFemale

Does the child have siblings?
YesNo

Please list the name, and age for each family member.

Is the child actively receiving treatment?
YesNo

Child’s diagnosis & when they were diagnosed

Summary of the child’s treatment

Where is the child being treated?

Can the child be around groups of people?
YesNo

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

Does your child have any physical restrictions? If so, please describe. (i.e. can they be outdoors?)

Parent’s Information

Parent’s name

Parent’s email

Parent’s phone

Parent’s Home Address

Parent’s social media account URLs

Does the family live in the US?
YesNo

If living in the US, what state do they live in?

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

How did you hear about Leia’s Kids?

Please upload a picture of your warrior here

Social worker name, email and number