Youth Participant Application

Home > Youth Participation

Youth Interest Form

We gather information about every participant to better understand who comes to our program. Personal information will be kept confidential. As a non-profit organization that does not charge for our services, we rely solely on donations to underwrite our program and need the following information to help secure funding. Information provided to funders does not include identifying information. Your answers will, in no way, affect your ability to access all programs at Gilda’s Club Quad Cities at no charge. THANK YOU!

Youth Participant Form
Location

Youth’s Information

Youth’s Gender
Youth’s Language
Youth’s School District
Youth’s Address
Youth's Address
City
State
Zip
This youth is registering as a:
Has the cancer diagnosis been discussed with your youth?

Parent/Guardian Information

Relationship

Emergency Contact (if different from above)

Is the above Parent/Guardian this youth’s Emergency Contact:
Relationship

Health

Does your youth have any allergies?
Does your youth have any sensory needs (i.e. lighting and sound sensitivity)?
Does your youth have any accessibility needs?
Does your youth have any behavioral or emotional needs that our staff/volunteers should be aware of?
Has your youth participated in any cancer support groups/activities previously?
Our goal to to ensure your youth has a safe and supportive experience while at CSCIAIL. Would you like the Children, Teens, and Family program manager to contact you to further discuss your youth’s needs?

The following information is optional. It help’s Cancer Support Community at Gilda’s Club qualify for assistance from funders and granting organizations. It will remain confidential.

Race/Ethnicity