For Parents

The following questionnaire (which will be kept strictly confidential) will be added to the Cure Our Kids data base so we can inform you about future Family Groups, Events etc.

Child In Treatment
First Name: *	Surname:
Date of Birth:	Gender	Male Female
Home Address:
Diagnosis:	Date

Caregivers
Mother Father Other
First Name: *		Surname:
Address:
Ph (HOME):		Ph (BUS):
Mobile:		Email: *
Occupation:

Caregivers
Mother Father Other
First Name:		Surname:
Address:
Ph (HOME):		Ph (BUS):
Mobile:		Email:
Occupation:

Siblings
First Name:		Date of Birth:
First Name:		Date of Birth:
First Name:		Date of Birth:

Comments