If you have a child with cancer and you think they could benefit from the treats and wishes provided by the Rae Rae Trust then please fill in the form below to contact us with the details.

Personal Information

Childs Name*

First

Last

Age*

Siblings Names and Ages

Name Sibling 1

First

Last

Age Sibling 1

Name Sibling 2

First

Last

Age Sibling 2

Name Sibling 3

First

Last

Age Sibling 3

Name Sibling 4

First

Last

Age Sibling 4

Parents / Carers Names*

E-mail:*

Home Phone

Area Code

Phone Number

Mobile

Other

Address:

Street AddressStreet Address Line 2CityPost Code

1/4

The Childs Story

Name/Type of Cancer*

Please provide a brief story of their diagnosis and prognosis*

Treatment received/receiving*

Name of Hospital*

Full Address of Hospital

Street AddressStreet Address Line 2CityPostal Code

Name of Lead Doctor

2/4

Treats/Days out information

The Childs Dreams and Aspirations*

Childs likes and dislikes and ideas for treats /days out*

Are there any restrictions / limitations*

Interaction with other Charities*

Treats/days out already received*

3/4

Additional Information

Any Additional Supporting Information

Sharing the Trusts Work

Consent to publicize story on our website and social media (we would also need a couple of pictures of child and siblings/family)

Permission to Share Photos/Story on Social Media & Website*

Yes

Date Form Completed*

Signature: (full name if completed electronically)*

4/4

Treats Contact Form

Personal Information

The Childs Story

Treats/Days out information

Additional Information

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