Contact Information First Name * Last Name * Email * Telephone * Street Address * City * State * - Select -ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVIVAWAWVWIWY Zip * Patient Information Patient’s First Name * Patient’s Last Name * Patient’s Date of Birth * Year Year19751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Patient’s Gender * - Select -MaleFemale Patient's Ethnicity * Patient’s Diagnosis * Date of Diagnosis * Year Year19751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Treatment Status * - Select -In treatmentOff treatmentWatch and waitNo evidence of diseasePassed Away Date of Passing Year Year19751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024202520262027 Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Patient’s Hospital Your Relationship to Patient * First and Last Name and Date of Birth of all Siblings What is the primary language spoken in your household (i.e. English, Spanish, etc.)? * Resources I’m interested in receiving information on: Receiving Family Services Resources Finding Clinical Trials Learning about Tissue Donation Getting Involved With Fundraising and Awareness Learning about ALSF’s Research Projects Would you like to receive information by mail or email? * - Select -Mail Email Would you like a free copy of the ALSF Treatment Journal organizer? * - Select -YesNo Select your language option for the ALSF Treatment Journal organizer. * - Select -EnglishSpanish Would you like a free copy of the ALSF School Guide? * - Select -YesNo Which version of the School Guide do you prefer? * - Select -E-Book PDFPrinted Would you like a free copy of “Alex and the Amazing Lemonade Stand"? * - Select -YesNo Information about the Alex and the Amazing Lemonade Stand book here. Do you want to enroll your child's sibling(s) in SuperSibs? (siblings ages 4-18) * - Select -YesNo Which program do you want to enroll in? * Comfort and Care Grief and Loss (bereaved siblings) Information about SuperSibs here. How were you referred to Alex’s Lemonade Stand Foundation? * Please describe. Would you like to receive ALSF e-newsletters? * - Select -YesNo Terms and Conditions of SuperSibs Program I attest and agree to the following: (a) I am the parent/guardian of the patient and siblings listed on this application. (b) If representing the family, a parent or guardian has given his or her consent to provide the information in this application, as well consent to the release of medical and contact information, and has agreed to sign any additional forms and consents related to this application. (c) The information provided in this application is truthful and accurate. ALSF shall be immediately notified if any information in this application changes, including the family's address or patient's medical condition. (d) ALSF will not be responsible or liable for any reason to the family or the representative, regardless of whether or not ALSF supports this applicant or any other applicant. (e) I understand the program is limited by available resources and may be discontinued or changed at any time. (f) I hereby give ALSF consent to use my information listed in this application and to contact me to discuss the information contained in this form. (g) I understand, or have expressed to the family, that I/they may be contacted by SuperSibs or affiliates regarding this program or related topics including, but not limited to, the opportunity to participate in research. These are optional programs and participants may opt out at any time. Do you agree? * I agree Leave this field blank
