Registration Form Fields marked with an * are required Child's Full Name * Child's Date of Birth * Child's Gender * Female Male Child's Nationality * Main Hospital providing treatment * National University Hospital (NUH) KK Women's and Children's Hospital (KKH) Mount Alvernia Hospital Others Name of Doctor/Specialist providing treatment * Childhood Cancer Diagnosis * Date of Childhood Cancer Diagnosis (DD-MM-YYYY) * Child's Treatment Stage * Undergoing treatment Remission 1-3 years Remission 3-5 years Remission 5+ years Palliative Care Others Date of Remission (if applicable) Caregiver's Full Name * Caregiver's Email * Caregiver's Relationship * Caregiver's Contact No. * Caregiver's Address * Do you have other children who may be interested in our programs? If so, please input their names and date of birth * How did you learn about LOVE, NILS? * Hospital flyers Doctor Nurse Care Coordinator LOVE, NILS staff Through other parents/friends/family Toy Donation Others What programs are you interested in? * Online Art Therapy Sessions Art Kit - monthly art kits sent to your local address Calendar of Hope - free tickets to events, plays and activities Caregiver Support Group Education Support HTML LOVE, NILS Terms & Conditions and Data Privacy & Protection Policy I consent to LOVE, NILS, its employees and agents and its authorised third-party providers to collect, use, disclose and/or process any of the above information for the following purposes (“Purposes”): - (a) contacting me on LOVE, NILS programmes and services; (b) sending me marketing, advertising, and promotional materials and (c) research and analysis to improve LOVE, NILS programmes and/or services. * I consent to LOVE, NILS disclosing the above information (including any personally identifiable information) to: - (a) the Government of the Republic of Singapore (including ministries); (b) any other statutory body; and (c) any entity that support the programmes of LOVE, NILS, for the Purpose, and any other purpose deemed appropriate by LOVE, NILS * I would like to receive information on LOVE, NILS programmes, events, and services. * Whatsapp Email Whatsapp and Email No I give my consent for photographs and videos that could be taken during event(s) to be used for LOVE, NILS publicity purposes (if any). * Yes No If you are a human seeing this field, please leave it empty.
