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Nice to meet you . Tell us a bit about yourself!

I’m a

of
decent.
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CanTeen is for young people who are 13 years old or over.
We’d love to have you when you turn 13!
For now, we’d recommend you get in touch with The Child Cancer Foundation.

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CanTeen is for people 13-24 years old.
But there are lots of other support options for adults.
For more info or to get in touch please email info@canteen.org.nz

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Where do you live in New Zealand?

I live in
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What’s your current situation?

I’m currently .
My NHI number (if you know it) is .

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Tell us about your diagnosis.

In of
I was diagnosed with .
I currently receiving treatment.

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Do you have brothers or sisters?

I have brothers and sisters.

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Can you tell us more about your sibling?

My brother or sister

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Due to their age, are also eligible to join CanTeen.

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Because you’re under 18, we need to know it’s OK to contact you.

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Oops. You’ll need permission from a parent or guardian. Please come back to this form when you’re ready.

Ok

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Thanks . Is there anything else you’d like to tell us about yourself? For example, if you have any visual impairments or medical implants?

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Please let us know how we can get in touch with you.

My email address is . My phone number (including area code) is , and my postal address is, .

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How would you like us to contact you?

Please contact me by
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Who can we contact in case of an emergency?

The young persons emergency contact is their , whose name is . Their email address is email , and phone number (including area code) is .

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Who can we contact for in case of emergency?

's emergency contact is my , whose name is . Their email address is email , and phone number (including area code) is .

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Thanks . You’re all done, we’ll be in touch soon!

In the meantime, why not check out some stories from Canteeners, or learn more about how we can help.

What’s your family relationship with cancer?

I a brother or sister with cancer.

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Do you have other brothers or sisters?

I have brothers and sisters.

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Can you tell us more about your other sibling?

My other brother or sister

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We’re sorry for your loss. Please tell us a little about them.

My sibling, , was diagnosed with . They passed away in of .

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Tell us about your sibling living with, or who survived cancer.

My sibling, ,
was diagnosed with .
They currently receiving treatment.

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What’s your family relationship with cancer?

I a parent or guardian with cancer.

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We’re sorry for your loss. Please tell us a little about them.

My

, was diagnosed with . They passed away in of .

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Tell us about your parent living with, or who survived cancer.

My , was diagnosed with .
They currently receiving treatment.

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Nice to meet you . Who would you like to refer to CanTeen?

I’d like to refer .
They are

of decent,
born on
.

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Where does live in New Zealand?

lives in
.
Their nearest CanTeen branch is .

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What is 's current situation?

is currently .
Their NHI number (if you know it) is .

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Tell us about 's diagnosis.

In of was
diagnosed with .
They currently receiving treatment.

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Does have brothers or sisters?

has brothers and sisters.

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Can you tell us more about 's sibling (please fill in as much as you can)?

's brother or sister

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Because is under 18, we need to know it’s OK to contact them.

's parents or guardian says it’s for CanTeen to contact them.

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Thanks . Is there anything else you’d like to tell us about ? For example, if you have any visual impairments or medical implants?

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Please let us know how we can contact .

's email address is . Their phone number (including area code) is , and their postal address is .

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How would prefer to be contacted?

Please contact by
.

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16 Mar, 2018