Join Candlelighters

Welcome, new Candlelighters families.

We understand that when a child is diagnosed with cancer, it affects each member of your family differently. When you join Candlelighters, our free programs and services are here for your whole family. From diagnosis through treatment and beyond, there will always be a place for you in our community of hope.

To join Candlelighters, please fill out the form below in its entirety. If you have any questions regarding this form or process, please reach out to your social worker or contact Candlelighters.

Family Information

Candlelighters programs and services are free of charge to children and teens age 0–21 who have experienced cancer, and to their immediate family members.

Parent / Guardian 1 Name(Required)

First Last

Parent / Guardian 1 Language Preference(Required)

Parent / Guardian 2 Name

First Last

If first name is entered, last name is required.

Parent / Guardian 2 Language Preference

Name of person filling out form if different from parent / caregiver:

Role of person filling out form if different from parent / caregiver:

Street Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Mailing Address (if different)

Street Address City State / Province / Region ZIP / Postal Code

Preferred Phone(Required)

Email(Required)

Served Child Information

Name of Child with Cancer(Required)

First Last

Child with Cancer’s Language Preference(Required)

Child with Cancer’s Gender

Male

Female

Non-Binary

Child with Cancer’s Date of Birth(Required)

Month

Day

Year

Diagnosis(Required)

Bone

Brain / CNS (Central Nervous System)

Carcinoma

Germ Cell

Hepatic

Leukemia

Lymphoma

Renal

Retinoblastoma

SNS (Sympathetic Nervous System)

Soft Tissue

Other (please describe in box)

Diagnosis: Other

Enter the Diagnosis here if none of the Diagnosis options are appropriate.

Date of Diagnosis

Month

Day

Year

Hospital(Required)

Doernbecher Children’s Hospital

Randall Children’s Hospital

Rogue Valley Medical Center

Shriners Hospital

Other

Other Hospital

Social Worker(Required)

First Last

If first name is entered, last name is required.

Doctor

First Last

If first name is entered, last name is required.

Current Status(Required)

Active Treatment

Remission

Deceased

Hospice

Survivor

Treatment Start Date

Month

Day

Year

Does the affected child have siblings?(Required)

Sibling Information

Sibling 1 Name

First Last

If first name is entered, last name is required.

Sibling 1 Date of Birth

MM slash DD slash YYYY

Sibling 1 Gender

Male

Female

Non-Binary

Sibling 2 Name

First Last

If first name is entered, last name is required.

Sibling 2 Date of Birth

MM slash DD slash YYYY

Sibling 2 Gender

Male

Female

Non-Binary

Sibling 3 Name

First Last

If first name is entered, last name is required.

Sibling 3 Date of Birth

MM slash DD slash YYYY

Sibling 3 Gender

Male

Female

Non-Binary

Sibling 4 Name

First Last

If first name is entered, last name is required.

Sibling 4 Date of Birth

MM slash DD slash YYYY

Sibling 4 Gender

Male

Female

Non-Binary

Sibling 5 Name

First Last

If first name is entered, last name is required.

Sibling 5 Date of Birth

MM slash DD slash YYYY

Sibling 5 Gender

Male

Female

Non-Binary

Connecting with Candlelighters

Candlelighters offers resources such as financial assistance, support groups, a youth group (for ages 13–21), free family activities, and an annual family camp.

I would like to receive Candlelighters emails to stay up to date on resources.

Yes.

I'd like to know more about the following Candlelighters Chapter

Mid-Willamette Valley

Bend

Southern Oregon

I would like to receive a call from Candlelighters so I know what resources are available to me.

Yes.

How did you hear about Candlelighters?

Candlelighters Event

Candlelighters Staff

Friends or Family

Hospital Employee

Marketing Materials (poster, flyer, etc.)

Online Search

Other

Family Data (Optional)

We are interested in learning more about our families, as well as collecting information that will allow us to apply for grant funding in the future. We greatly appreciate you providing answers to the following questions. Please note that these questions are optional and all answers will be kept confidential and will have no impact on the approval process for any of our programming.

Race & Ethnicity

Please check all that apply.

Hispanic / Latino

Asian or Asian American

African American or Black

Native Hawaiian or Pacific Islander

American Indian or Alaska Native

Arab or Middle Eastern

White or Caucasian

Other

Decline to Answer

Military Status

Not a Veteran

Veteran

Occupation of Parent / Guardian 1

Highest Level of Education for Parent / Guardian 1

High School

Some College

College Degree

Graduate Degree

Occupation of Parent / Guardian 2

Highest Level of Education for Parent / Guardian 2

High School

Some College

College Degree

Graduate Degree

Total Household Income:

Less than $10,000

$10,000 - $24,999

$25,000 - $39,999

$40,000 - $49,999

$50,000 - $74,999

$75,000 - $99,999

$100,000 and above

Do you receive Medicaid?

Yes

Untitled

First Choice

Second Choice

Third Choice

Welcome to Candlelighters

We’re glad you are joining us to connect with other families, programs, and services for families diagnosed with childhood cancer.

We’ll be in touch if you asked us to contact you. If you have questions about Candlelighters, please contact Nicole If you have questions about your diagnosis date, diagnosis, or treatment status, please contact your social worker at Doernbecher Children’s Hospital or Randall Children’s Hospital.