Referral Form

How do children/teens get into the SuperSibs! program?

SuperSibs! provides ongoing support via the US mail to children between the ages of 4 and 18 who have a brother or sister battling cancer. (SuperSibs! also serves those siblings who are bereaved.) To get kids into the program, a referral form must be completed by either a parent, medical or psycho-social professional, educator, family member or family friend.

This "referral form" gathers basic information that will allow SuperSibs! to provide the most appropriate support materials based on the age of each individual sibling.

If you are interested in referring a child to SuperSibs! please complete our referral form. Scroll down to fill out the online form below. Or click here (English or Espanol) to download a pdf referral form to email or fax to SuperSibs! Please be patient as it may take a minute or so to download and open. You will need Acrobat Reader to view the form, which is a free download from Adobe.

If you have questions, please feel free to contact SuperSibs! at 847-705-7427 (SIBS) or toll free at 866-444-7427 (SIBS).

Thank you for your part in supporting these "shadow survivors," and helping them manage through the pediatric cancer journey with strength, courage and hope!

Your referral information will be kept completely confidential by SuperSibs! Information is not shared, sold or disclosed to anyone outside our organization. Your referrals are directed to our secure database for processing and for program services to begin.

* indicates required information

Referral Information
Your Name (first/last): *
Email: *
Your relationship
to the sibling:		 *
  If you chose parent/guardian as the referrer, please move on to the Family Information section below.  
Your Title:  
Hospital/Organization Name:  
Work Phone:  
Fax:  

Family Information

Parent Name #1 (first/last): *
Parent Name #2 (first/last):  
Street Address: *
Apartment/Unit:  
City: *
State/Province: *
Country: *
Zip/Postal Code: *
Home phone: *
Work phone:  
Cell Phone #1:  
Cell Phone #2:  
Email: *
Language: *
Ethnicity: *

Patient Information

Name (first/last): *
Birthdate (m/d/y): *
Gender: *
Diagnosis: *
Diagnosis Date(m/d/y): *
Hospital/Organization Name: *
Doctor's Name (first/last):
(if known)		 *
Doctor's phone:
(if known) 		 

Bone Marrow/Stem Cell Information (If applicable)
Actual or anticipated date: optional
Unrelated Donor?: optional
Sibling Donor?
(name of sibling - first/last): 		optional

Sibling #1 Information

PLEASE indicate correct birthdates for EACH sibling.
Name (first/last): *
Gender: *
Birthdate (m/d/y): *
Ethnicity: *
Notes:  

Sibling #2 Information

PLEASE indicate correct birthdates for EACH sibling.
Name (first/last):  
Gender:  
Birthdate (m/d/y):  
Ethnicity:  
Notes:  

Sibling #3 Information

PLEASE indicate correct birthdates for EACH sibling.
Name (first/last):  
Gender:  
Birthdate (m/d/y):  
Ethnicity:  
Notes:  

Sibling #4 Information

PLEASE indicate correct birthdates for EACH sibling.
Name (first/last):  
Gender:  
Birthdate (m/d/y):  
Ethnicity:  
Notes:  

Additional Sibling Information

PLEASE indicate correct birthdates for EACH sibling.
Please indicate the following information for each additional sibling: Name (first/last), Gender, Birthdate (m/d/y), Ethnicity  

Miscellaneous

Anything Else you'd
like us to know?
(If siblings are bereaved, please indicate information here.)

 You will receive a confirmation email with program information from referral@supersibs.org after you submit your referral. Please check your SPAM/JUNK mailbox if this email is not received within a few hours. Again all submitted information is kept completely confidential.