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Youth Participant Application

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  • Gilda's Club

Youth Interest Form

We gather information about every participant to better understand who comes to our program. Personal information will be kept confidential. As a non-profit organization that does not charge for our services, we rely solely on donations to underwrite our program and need the following information to help secure funding. Information provided to funders does not include identifying information. Your answers will, in no way, affect your ability to access all programs at Gilda’s Club Quad Cities at no charge. THANK YOU!

Youth Participant Form
Location

Youth’s Information

Youth’s Sex
This youth is registering as a:
Youth’s School District

Parent/Guardian Information

Relationship
Address
Address
City
State
Zip
Source

Non Parent or Guardian

Is someone other than the Parent/Guardian completing this form?
Relationship

Emergency Contact (if different from above)

Is the above Parent/Guardian this youth’s Emergency Contact:
Relationship
Source

Health

Does your youth have any allergies?
Does your youth have any behavioral/psychiatric issues that would be helpful for our staff/volunteers to be aware?
Who in your youth’s life has been diagnosed with cancer
Have you discussed the cancer diagnosis with your youth?
Has the cancer diagnosis affected your youth’s behavior?

The following information is optional. It help’s Gilda’s Club qualify for assistance from funders and granting organizations. It will remain confidential.

Race/Ethnicity

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“Everyone impacted by cancer receives the support they want and need throughout their experience.”

Quick Links

Programs

Our Locations

Davenport Clubhouse
1351 W Central Park Ave
Suite 200
Davenport, IA 52804
Moline Clubhouse

600 John Deere Road
Suite 101
Moline, IL 61265

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