You can also print our Application Form (PDF), fill it out it and send it to:
Galia and Friends
227 East 57th Street
Suite 17C
New York, NY 10022
Please fill out this form, print it, and send it to Galia and Friends. | |||
| *Date: | |||
| *Child’s Name: | *DOB: | ||
| *Date of Diagnosis: | *Diagnosis: | ||
| *Hospital Name: | *Oncologist: | ||
| *Hospital Affiliation: | *Telephone: | ||
| *Email: | *Fax: | ||
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| *Social Worker: | *Telephone: | ||
| *Email: | |||
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| Other: | Telephone: | ||
| Email: | |||
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| *Care-giving Parents: | *Address: | ||
| *Address 2: | *Telephone: | ||
| *Cellphone: | *Email: | ||
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| *Psychosocial background (information to be filled out by the social worker): | |||
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| *Primary Care Oncologist: | |||
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STATEMENT | |||
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| *Telephone: | *Date: | ||
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