TCP Caregiver Registration

Caregiver Registration

A caregiver is defined as a person who helps an individual diagnosed with cancer (within FIVE years of diagnosis) with daily living activities including assisting with medication, bathing, dressing, meal preparation, and doctor’s appointments.

Email
This field is for validation purposes and should be left unchanged.
Name*
Please provide your full name.
First Last
Email*
Primary email for contact by NVCCF.
Phone*
Primary phone for contact by NVCCF.
Home Phone
Date of Birth*
Month
Day
Year
Widowed
Patient Name*
First Last
Patient Phone*
Patient Email
Patient Oncologist Name
Permission to Verify Information*
Emergency Contact Name*
First Last
Emergency Contact Email*
Emergency Contact Phone*
Emergency Contact Relation*
Home Healthcare Agency
If professional caregiver.
Agency Phone
If professional caregiver.
Signature*
I understand that as a caregiver, I will be permitted to participate in group activities with my participant. Individual sessions such as massage, reflexology and Reiki will be available on a limited basis as priority is given to cancer survivors and those currently in treatment. All answers and statements on this registration and any other materials I have submitted to apply as a particiapnt in The Caring Place programs and services are true and complete to the best of my knowledge. I understand that The Caring Place may verify this information. Untruthful or misleading answers are cause for rejection of this registration.
Signature Date*
Month
Day
Year

Caregiver Registration

Our mission is to provide social, educational, financial and psychological support services and programs to families of all children diagnosed with life threatening or critical illnesses.

Nevada Childhood Cancer Foundation

3711 Sunset Road, Las Vegas, Nevada 89120

phone: 702.735.8434

email: info@nvccf.org

Donation Form