Candidate TypeNomination from family" "From a third party"]

Name

Nomination Date

National ID card/passport number

Expiry Date

Phone Number

E-mail

His relationship to the candidate:

The child's full name

Birth date

Identity card/passport number

Expiry Date

Age

Parent's full name

Parent's phone number

Parent's address

Parent's email

Cancer type
— الرجاء تحديد اختيار —LeukemiaSarcomaBrain TumorsSolid TumorsKidney TumorLymphoma CancerOther

Date of diagnosis

Age at diagnosis

Age at the last dose of treatment

Current health status

Please tell us where you have been treated or are still being treated

Any health problems other than cancer

Please tell us in no more than 300 words how this child has maintained a positive attitude and strong resolve in the face of cancer?

Please tell us in no more than 300 words how this child has demonstrated the intention for me to receive all forms of medical treatment?

Please tell us in no more than 300 words how the medical and other circumstances relating to this child were so complex that they required additional determination?

Please tell us in no more than 300 words how this child has become an inspiration for other children and a role model?

How did you learn about this award? (Please select all that apply)