Candlelighters New Family Form

Social Worker(Required)

New Family Information

Candlelighters programs and services are free of charge to children and teens from newborns to age 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

This child does not have a second parent/guardian

Parent / Guardian 2 Name(Required)

First Last

Parent / Guardian 2 Language Preference(Required)

Parent / Guardian Marital Status(Required)

Partnered/Married (One Household)

Single/Separated/Divorced (Two Households)

Parent / Guardian 1 Contact Information

Street Address(Required)

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

County

Different Mailing Address

Mailing address is different from street address

Mailing Address(Required)

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

County

Phone contact preference

Cell Phone

Home Phone

Work Phone

Select all that apply

Opt in to receive text messages from Candlelighters(Required)

Yes

Cell Phone(Required)

Home Phone(Required)

Work Phone(Required)

Email(Required)

Email Info

Parent/guardian has no email address

Parent / Guardian 2 Contact Information

Parent / Guardian 2 Street Address

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

Different Mailing Address

Mailing address is different from street address

Mailing Address

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

Phone contact preference

Cell Phone

Home Phone

Work Phone

Select all that apply

Opt in to receive text messages from Candlelighters

Yes

Cell Phone

Home Phone

Work Phone

Email Info

Parent/guardian has no email address

Served Child Information

Name of Child with Cancer(Required)

First Last

Child with Cancer’s Language Preference(Required)

Child with Cancer’s Gender(Required)

Male

Female

Non-binary

Gender is not listed

Prefer not to answer

Child with Cancer’s Date of Birth(Required)

Diagnosis(Required)

Diagnosis: Other(Required)

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

Date of Diagnosis

Hospital(Required)

Doernbecher Children's Hospital

Randall Children's Hospital

Asante Rogue Regional Medical Center

Shriners Hospital

Other

Other Hospital(Required)

Current Status(Required)

Sibling Information

How many siblings does the affected child have?(Required)

Please enter a number from 0 to 8.

Sibling 1 Name(Required)

First Last

Sibling 1 Date of Birth(Required)

Sibling 1 Gender(Required)

Male

Female

Non-binary

Gender is not listed

Prefer not to answer

Sibling 2 Name(Required)

First Last

Sibling 2 Date of Birth(Required)

Sibling 2 Gender(Required)

Male

Female

Non-binary

Gender is not listed

Prefer not to answer

Sibling 3 Name(Required)

First Last

Sibling 3 Date of Birth(Required)

Sibling 3 Gender(Required)

Male

Female

Non-binary

Gender is not listed

Prefer not to answer

Sibling 4 Name(Required)

First Last

Sibling 4 Date of Birth(Required)

Sibling 4 Gender(Required)

Male

Female

Non-binary

Gender is not listed

Prefer not to answer

Sibling 5 Name(Required)

First Last

Sibling 5 Date of Birth(Required)

Sibling 5 Gender(Required)

Male

Female

Non-binary

Gender is not listed

Prefer not to answer

List additional sibling information here(Required)

Please list names, birth dates, and gender identity for additional siblings.

Family Data

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. All answers will be kept confidential and will have no impact on the approval process for any of our programming.

Race & Ethnicity(Required)

Select all ethnicities that apply to household

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 Veteran Status(Required)

A parent/guardian of this family is a military veteran

A parent/guardian of this family is an active duty member of the military

None

Select all statuses that apply; if parent/guardian not a military veteran or member, mark "None"

Connecting with Candlelighters

Candlelighters offers resources such as financial assistance, support groups, a youth group (for ages 13–21), free family activities, higher education scholarships, and opportunities for support for the whole family.

I would like to receive a phone call from Candlelighters Program Director, Nicole Ek, so I know what resources are available to me.

Yes

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

Central Oregon

Mid-Willamette Valley

Portland/SW Washington

Southern Oregon