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Community Impact Form
Please enable JavaScript in your browser to complete this form.
Are you reporting for yourself or someone else?
*
Self
Someone Else
Your Name
*
Your Name
Name of affected child
*
Type of cancer
*
Gender
*
Male
Female
Age at time of diagnosis
*
0-12 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Must have been between the ages of 0 - 19 at time of diagnosis
Gender of Child
*
Male
Female
Age of child at time of diagnosis
*
0-12 months
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Must have been between the ages of 0 - 19 at time of diagnosis
Year of diagnosis
*
City
*
The name of city/town you lived in at time of diagnosis
State
*
What state did you live in at time of diagnosis?
Zip Code
*
Zip Code of place you lived at time of diagnosis
City
*
The name of city/town child lived in at time of diagnosis
State
*
What state did the child live in at time of diagnosis?
Zip Code
*
Zip code of place child lived at time of diagnosis
How many years prior to diagnosis did you live in this zip code?
*
Less than a year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
How many years prior to diagnosis did the affected child live in this zip code?
*
Less than a year
1 year
2 years
3 years
4 years
5 years
6 years
7 years
8 years
9 years
10 years
11 years
12 years
13 years
14 years
15 years
16 years
17 years
18 years
19 years
Is the child deceased?
*
Yes
No
Please check this box if you still live in this zip code
Please check this box if the affected child still lives in this zip code
Yes
Email
*
Phone
Do you believe your cancer was caused by environmental contamination?
Yes
No
I don't know
Do you believe this child's cancer was caused by environmental contamination?
*
Yes
No
I don't know
Contamination Source(s)
Air
Water
Soil/Ground
Artificial Turf
Would you like to help Trevor's Trek with childhood cancer cluster investigations in your area?
*
Yes
No
Please provide any additional details you would like to share. We would love to hear your story!
We would love to learn more about your story. Please provide any additional details you would like to share.
Please check this box if you wish to keep your name private
I wish to keep my name private
Please check this box if wish to keep the child's name private
Please keep their name private
Message
Submit
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