Register Your Family – Pediatric Cancer the Lehigh Valley

Are you a Lehigh Valley area family dealing with a pediatric cancer diagnosis? If so, we can help! Complete the form below and we will have someone reach out to your to see how we can be of assistance. By submitting the form, I give permission to PCFLV to use a photograph of my child/children. I also give permission for them to contact other foundations for the purpose of networking and obtaining resources.

By submitting the form, I give permission to PCFLV to use a photograph of my child/children. I also give permission for them to contact other foundations for the purpose of networking and obtaining resources.

Child's Name

First Last

Child's Nickname

Child's Gender(Required)

Child's Birthdate(Required)

Parent #1 Prefix

Parent #2 Name(Required)

First Last

Parent #1 Email(Required)

Parent #1 Phone(Required)

Parent #2 Prefix

Parent #1 Name(Required)

First Last

Parent #2 Email(Required)

Parent #2 Phone(Required)

Who does the child reside with?(Required)

Parent #1

Parent #2

Both

Other

Child's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

County(Required)

School District/College(Required)

Child's Diagnosis(Required)

Diagnosis Date(Required)

Treating Hospital(Required)

Child's Allergies(Required)

Miscellaneous (hobbies, interests, favorite cartoon character, books. TV shows, sports, school subject)

Sibling #1 Name

First Last

Sibling #1 Gender

Sibling #1 Birthdate

Sibling #2 Name

First Last

Sibling #2 Gender

Sibling #2 Birthdate