BT Healthy Kids Online Support Group

BECOME A MEMBER

To join our group, please answer the following questions. When completed, please hit submit to send your request to the group facilitator.
(Please fill out every box. If it doesn't apply, type in "N/A".)

1. Your name and current location
(city, state, country):		  
2. Your email address:  
3. Patient's name and current location:
(city, state, country):		  
4. Patient's email address:  
5. Patient's date of birth:  
6. Specific tumor(s) location:  
7. Treatment types and dates:
8. Tumor Status and Date of Most Recent MRI :  
9. Neurological deficits, if any :  
10. What is your current condition?  
11. Please use the space below to tell us
how you have been affected.
All information will be distributed
only to other members of this group.
Your name and email address will be
used to add you as a member.
The additional information will be
used to introduce you to other member
of this group.
12. I give my permission to the facilitator to use my comments above to introduce me to the group. YesNo