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 Language Preference(Required)

Parent / Guardian 2 Language Preference(Required)

Parent / Guardian 1 Contact Information

County

Cell Phone(Required)

Home Phone(Required)

Work Phone(Required)

Email(Required)

Parent / Guardian 2 Contact Information

Cell Phone

Home Phone

Work Phone

Email

Served Child Information

Child with Cancer’s Language Preference(Required)

Diagnosis: Other(Required)

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

Other Hospital(Required)

Sibling Information

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

Please enter a number from 0 to 8.

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.

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.

Candelighters New Family Form