Super Kids Fighting Cancer Tee Shirt

Is your child currently fighting childhood cancer or a survivor of childhood cancer? We would love to send them one of our Super Kid Cancer Tee Shirts! Just fill out the form below to nominate your child and send it to us.

Child's Name

Please tell us your child's name.

First Name

Last Name

Parent's Name

Please tell us your name.

First Name

Last Name

Address

Please provide your home address.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

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Child's Age

Your child's age at the time.

Childhood Cancer Diagnosis

Please tell us they type of childhood cancer your child has been diagnosed with or has survived.

If Other cancer, please list.

If your child has a type of childhood cancer not listed, please provide us with his/her diagnosis.

Current State of Your Child's Cancer

Please let us know your child's current health state as it relates to their diagnosis.

Pediatric Oncologist/Hematologist's Name

Please provide the name of your child's Pediatric Oncologist/Hematologist.

First Name

Last Name

Tee Shirt Size

Please provide us with your child's tee shirt size.

Would you be willing to share a photo of your child with us in their tee shirt?

We love to see kids smiling in our tee shirt. Would you be willing to share a photo of your child with us and allow us to share it on social media and our website?

Yes

Tell Us More About Your Child or Teen

If you could, tell us more about your child or teen. What are their hobbies? What do they like to do? What makes them happy. We'll share this with our donors and Facebook audience should you provide us this information and give us permission to share your child's photo.

Your Facebook Support Page

If your child or teen has a Facebook support or "Team" page, cut and paste the address here and we'll mention this as well if we post your child's photo.

http://