Children's Healthcare of Atlanta

Parent/Guardian's Contact Information

Field Is Required First

Field Is Required Last

Field Is Required Email:

Yes! I want to be able to receive emails from Children's Healthcare of Atlanta Foundation staff, leaders, and programs.

Field Is Required Parent/Guardian's Phone Number

Field Is Required What's your relation to the patient?

Field Is Required Patient's First and Last Name

Field Is Required Patient's Birthdate

Field Is Required Patient's Address

Field Is Required Patient's City

Field Is Required Patient's State

Field Is Required Patient's Zip Code

Field Is Required Patient's Gender

Male
Female

Patient's School and Grade

Field Is Required Does the patient have siblings?

If so, what are their names and ages?

What languages does your child speak?

Field Is Required Are parents bilingual?

Field Is Required Age when child began treatment at Aflac Cancer and Blood Disorders Center

Field Is Required Primary Aflac Cancer and Blood Disorders Center location where the child received treatment

Egleston Hospital
Hughes Spalding Hospital
Scottish Rite Hospital

Field Is Required Is your child comfortable sharing about his/her Aflac Cancer and Blood Disorders Center journey?

Field Is Required Diagnosis (Maximum response 255 chars, approx. 5 rows of text)

Field Is Required Please share the patient's story of his/her time at the Aflac Cancer and Blood Disorders Center or the link to a website that share's their story (i.e. Caring Bridge, Facebook, etc.) (Maximum response 255 chars, approx. 5 rows of text)

Field Is Required Please share any talents/hobbies or other interests

We work very closely with many Georgia sports teams (both professional and collegiate). Does the patient have a particular interest in any?

Field Is Required My family is interested in

Event participation
Provide patient artwork
Raising awareness for the Aflac Cancer and Blood Disorders Center
Host a fundraiser
All of the above

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