Recommend a child - Big Dreams

"*" indicates required fields

Name (Parent or Guardian)*

First Last

Child's Name*

First Last

Child's type of cancer*

Date of diagnosis*

Contact Information

Email*

Phone*

Preferred method of contact?*

Phone

Other

Your Address*

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

How did you learn about Big Dreams?*

Which applies to you?*

I am the parent or guardian of a child diagnosed with cancer.

I am a childhood cancer survivor.

Child's Name*

First Last

Child's date of birth*

Diagnosis*

Diagnosis Date*

Tell us what you’d like us to know about your child. Ideas can be favorite things, hobbies, what makes them who they are, biggest challenges and current status*

Optional: Upload a photo

Accepted file types: jpg, jpeg, png, gif.

Do you share your story on CaringBridge, Facebook , Instagram or other platform?? If so, you can share your link here:

Date of birth*

Diagnosis*

Diagnosis Date*

Tell us what you’d like us to know about you. Ideas can be favorite things, hobbies, what makes you who you are, biggest challenges and current status*

Optional: Upload a photo

Accepted file types: jpg, jpeg, png, gif.

Do you share your story on CaringBridge, Facebook , Instagram or other platform?? If so, you can share your link here:

Would you like to be in-the-know about research updates and other news specifically for pediatric cancer families?*

Yes

Children's Cancer Research Fund Authorization for Photography, Filming or Interviewing & Photo Sharing

I hereby expressly grant to Children's Cancer Research Fund the right to make, use and/or publish information, photographs, or any other reproductions of my physical likeness for communications efforts, such as pamphlets, booklets, videotapes, audiotapes, slideshows or Children's Cancer Research Fund’s Internet Web site, and social media sites. In addition, I expressly grant this right to be used for educational, marketing and/or promotional information by Children’s Cancer Research Fund for its professional and staff communications, public relations, marketing (including social networking websites such as YouTube, Facebook, and Instagram), and fundraising appeals. I understand that Children’s Cancer Research Fund shall not be responsible for external media’s use of any films, photographs or interviews, or any information that I have consented to release. Children’s Cancer Research Fund may use resulting media coverage in its internal or external promotional activities.

The foregoing consent is subject to the following LIMITATIONS:*

Indicate any limitations or NONE.

For minors: I, the undersigned hereby state that I am the parent or legal guardian of the child and do hereby consent and give my permission to this Agreement. I have read the above authorization, release and agreement and am fully aware of all that it states or implies.

Today's Date*

Signature*