CURE's Kids Sign-up Form

CURE's Kid's first name(Required)

CURE's Kid's last name(Required)

My Child is(Required)

On Active Treatment

Has Completed Treatment

Deceased

Diagnosis/Cancer type(Required)

Diagnosis Date(Required)

Current Age(Required)

Please tell us about your child and his or her cancer story(Required)

What are your child's likes or interests?

What does your child want to be when he or she grows up?

My Fundraising Goal is(Required)

$250

$500

$1000

Other

If you could tell people one thing about childhood cancer, what would it be?(Required)

Upload a picture (**no collages or videos please.)(Required)

Max. file size: 20 MB.

Parent's full name(Required)

Address(Required)

City State

Email address(Required)

Cell Phone(Required)