Child's Full Name (required)

Child's Date of Birth

Child's Nickname

Type of Cancer


Date of Diagnosis

Child's Website

Status Of Treatment

Other Relevant Health Info

Family/Parent Name(s)

Relationship with Child

Home Address

Home City

Home State

Home Zip

Home Country

Home Phone

Email Address

Mobile Phone

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Home Phone

Emergency Contact Work Phone

Emergency Contact Mobile Phone

Sibling Names(separate with commas)

Sibling Genders

Temporary Housing Name

Temporary Housing Address

Temporary Housing City

Temporary Housing State

Temporary Housing Zip

Temporary Housing Phone

Length of Time in Temp Housing

How did you hear about Candlelighters, NYC?


Please enter the characters from above.

Photo Release Form – Please sign and mail to:  Barbara Zobian, 345 East 73rd St. apt. 2L, New York , NY 10021

After filling out the photo release and mailing it off to Barbara, please fill out the form below. You will then be able to participate in all the fun activities!  You can also download and print the form: Signup Form