Family Profile Form

The Brain Tumor Foundation for Children invites you to complete our Family Profile Form so that you can join our family database. In so doing, you will receive emails, our newsletter with valuable and interesting information, as well as notices about social activities available for your child and your family. There is no charge for any of our services or activities and we will not give or sell your address to anyone.

Patient First Name (*)

Please let us know your name.
Patient Last Name (*)

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Nickname

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Sex (*)

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Date of Birth (*)

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Race (*)

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Ethnicity

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Primary Language (*)

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Treatment Facility (*)

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Primary Physician

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Diagnosis (*)

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Date of Diagnosis (*)

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Date of Death if applicable

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Name of Parents or Guardian (*)

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Street Address (*)

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City (*)

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State (*)

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Zip Code (*)

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County (*)

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Home Phone

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Work Phone

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Cell Phone

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Email Address 1

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Email Address 2


Please list any websites or Facebook pages you use to update family and friends on your child's health. We would like to keep up with your family that way also

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Sibling Name

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Sibling DOB

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Sibling Sex

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Sibling Name

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Sibling DOB

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Sibling Sex

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Sibling Name

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Sibling DOB

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Sibling Sex

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Anything special you would like to tell us about your child? Ex: hobbies, likes/dislikes, etc.

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How did you hear about us?

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Authorization for Information Exchange

I hereby authorize the staff of the Brain Tumor Foundation for Children, Inc. to obtain information from and/or provide information to the medical staff at the treatment facility listed above (*)

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Signature of Parent or Guardian (*)

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By entering your name, you electronically authorize as specified in the above document.

Relationship to Patient (*)

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NOTE: The release of information may be revoked at any time by the persons signed above. All revocations must be made in writing and signed by persons above.

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