KOURAGEOUS KIDS ROCK!!!!!!!!!

KOURAGEOUS KIDS ROCK!!!!!!!!!
The ASK Childhood Cancer Foundation is now recruiting for our
2013 Kourageous Kids promotion. This exciting, all ages,
promotion will represent the hope and courage of our ASK Kids in
treatment for childhood cancer. We partner with Commonwealth
Photography to produce colorful portraits of our Kourageous Kids
that we utilize in many mediums throughout the year. We have a
traveling display that is set up at various locations throughout
Central Virginia. Portraits are used in the ASK website, in ASK
promotional materials and in social media. . We hold a kickoff
party in September at the Children’s Museum to honor all the
children, along with their families and friends, who have been
treated for childhood cancer at the ASK Pediatric
Oncology/Hematology Clinic, Children’s Hospital of Richmond.
ASK would like you to be a part of this very special project. Help
us increase awareness of local children battling childhood cancer!!
The only requirement is for you to fill out the attached form and
submit it to ASK by June 1. We will contact you to discuss
scheduling a no cost photo session at Commonwealth Photography.
Your photo session will need to be reserved prior to June 30.
Questions contact Debra Abney, ASK ED, (804)501-8659 or
dabney@askweb.org
Answers below can be written by an older child or the parent for a younger
child.
CHILD’S
NAME____________________________________________________
My birthday is:____________________________________
PARENT
NAME____________________________________________________
ADDRESS_________________________________________________
_________________________________________________________
_________________________________________________________
PHONE___________________Email____________________________
DIAGNOSIS___________________________DATE________________
Sibling names and
ages:_____________________________________________________
_________________________________________________________
_________________________________________________________
When I grow up I want
to:_______________________________________________________
_________________________________________________________
_________________________________________________________
Hopes &
Dreams:___________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Favorite Color:__________________________
How has ASK
helped?___________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
Favorite ASK
program:__________________________________________________
_________________________________________________________
_________________________________________________________
If you could give a shout out to one of our ASK clinic staff, who would it be
and
why?_____________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
If you were a musician/Rock Star Who would you be and
why?_____________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
My favorite thing to do
is:_______________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
What makes me
smile?____________________________________________________
_________________________________________________________
_________________________________________________________
_________________________________________________________
T-shirt size:_______________
PARENTAL PERMISSION FOR PHOTOGRAPY (child under 18yo)
Sign_______________________________________Date___________
Submitted by_______________________________Date____________
Please return to Debra Abney P.O. Box 17184 Richmond, VA 23226
Phone: (804) 501-8659 or submit by email to: dabney@askweb.org