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Gaven's Parents Syracuse Men's Lacrosse

CHILD INFORMATION
Child's Name
First Last
DATE OF BIRTH*
Date Format: YYYY dash MM dash DD
GENDER*
DIAGNOSIS*
DATE OF DIAGNOSIS
Date Format: YYYY slash MM slash DD
DIAGNOSIS DETAILS
PRIMARY TREATMENT HOSPITAL
Other Hospital
SOCIAL WORK / CHILD LIFE SPECIALIST'S NAME
First Last
Child's School Name
GRADE
Please input just the numerical grade. IE for third grade just input the number 3.
PARENT / GUARDIAN INFORMATION
Parent/guardian #1 name*
First Last
Parent/guardian #1 phone*
PARENT/GUARDIAN #1 EMAIL*
Parent/guardian #2 name
First Last
PARENT/GUARDIAN #2 PHONE
PARENT / GUARDIAN 2 EMAIL
HOME ADDRESS*
Street Address Address Line 2 City State ZIP Code
Note:

Your answers to questions related to race/ethnicity and family income will not be shared with anyone and will have no bearing on your eligibility or participation in Team IMPACT. We collect this information in order to better analyze our program as a whole and to ensure we’re delivering a high-quality experience for families of every background, identity, and income level.
Child Preferred Language*
Parent/Guardian Preferred Language*
FAMILY RACE / ETHNICITY*
Check all that apply
- White
- Black or African-American
- American Indian or Alaskan Native
- Asian
- Native Hawaiian or other Pacific Islander
- Latino
- Other (please specify)
Other Ethnicity
Languages Spoken
⌘ Cmd + click on Mac to multi select. Ctrl + click on PC.
FAMILY HOUSEHOLD INCOME*
Number of people in your household*
SOCIAL MEDIA INFORMATION
FACEBOOK CARE PAGE
TWITTER HANDLE
INSTAGRAM HANDLE
CARINGBRIDGE PAGE
How Did You Hear About Us*
- Camps
- Hospital
- Like-Minded Charity
- Social/Digital Media
- News Media (ie: newspaper, TV, online article)
- Team IMPACT Participant
- All in for CF/Vertex
- Other
ADDITIONAL COMMENTS

TEAM IMPACT MISSION

To provide a community where there was isolation, hope where there was despair, and boldness where there was insecurity.

Together, we champion.

500 Victory Rd, 3rd Floor
Quincy, MA 02171
617-801-0248
info@goteamimpact.org

I think it is an amazing program and every child living with a chronic illness should experience the joy related to friendships, to feel “normal’ just like everyone else! To laugh, grow, gain confidence and just have fun uninhibited by their challenges.”

Mindy Mother of Brenna matched with Temple University Field Hockey

Careers
FAQs
Contact

EMAIL ADDRESS*

500 Victory Road
Quincy, MA 02171
617-801-0248
info@teamimpact.org

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