Pediatric Cancer Support | Gold In Fight

Volunteer Form

Child's Name (Last, First)

Child's Date of Birth

Diagnosis

Age at Diagnosis

Parent / Guardian Name(s)

Email Address

Cell Phone Number

Mailing Address

Best way to contact parent/guardian

City

State

Zip

Amount to Be Paid

Describe the bill you would like assistance with

Billing Company Name

Account number or information required to pay the bill

Have you recieved assistance from Gold in Fight in the past 12 months?

Mailing Address

City

State

Zip

Phone Number

To receive assistance, provide the name and contact number of your child's oncologist or social worker for verification of treatment.

Can we use your child's story and photos on Gold in Fight's social media and websites to help spread awareness? Please email their story and photos to goldinfight@goldinfight.org

Request Assistance

Family Assistance Request FOrm

Volunteer Form