Pediatric Brain Tumor Foundation
Working to eliminate the challenges
of childhood brain tumors
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Family Profile Form

The Pediatric Brain Tumor Foundation invites you to complete our family profile form to join our family database. We want to learn more about you to help us better understand how we can be of help. We’ll also send you informative emails about our programs and events. There’s no charge for any of our services or activities, and we will not give or sell your address to anyone.

Patient First Name*
Patient Last Name*
Nickname
Gender*
Date of Birth*
Child's Age*
Race*
Ethnicity*
Primary Language*
Treatment Status*
(hold the Ctrl key for multiple selections)
Treament Received*
(hold the Ctrl key for multiple selections)
Treatment Facility*
(Note: If your child is not longer in treatment, write where they had treatment.)
Primary Physician Name
Diagnosis*
Date of Diagnosis*
Date of Death (if applicable)
Name of Parents or Guardian*
Street Address*
City*
State*
Zip Code*
County
Home Phone*
Work Phone
Cell Phone
Email Address 1*
Email Address 2
Please list any websites or Facebook pages you use to update family and friends on your child's health.
Sibling Name
Sibling DOB
Sibling Gender
Sibling 2 Name
Sibling 2 DOB
Sibling 2 Gender
Is there anything special you would like to tell us about your child? Ex: hobbies, likes/dislikes, etc.
T-shirt sizes  
How did you hear about us?
Would you like to share your child's story?*
Your child's story Maxium length 1000 characters
Upload an image: Please upload a.jpg file, minimum 300 dpi, labeled with your child's first and last name.
Waiver:
I hereby authorize the staff of the Pediatric Brain Tumor Foundation to obtain information from and/or provide information to the medical staff at the treatment facility listed above.
Signature of Parent or Guardian*
By entering your name, you electronically authorize as specified in the above document.
Relationship to Patient*
 Captcha:*
Please enter the word shown in the image below.

     

* Required field or selection
NOTE: The release of information may be revoked at any time by the persons signed above. All revocations must be made in writing and signed by persons above.