Become a Riley's Army Family "*" indicates required fields Patient Name* First Last Patient birthdate* MM slash DD slash YYYY Parent/Guardian Name(s)*Mailing Address*Parent/Guardian Email Address(es)Parent/Guardian Phone Number(s)Does the child have any siblings? If so, please list them as well as their ages as well.*Please give a brief description of child's diagnosis including diagnosis date.*What is your social worker’s name?*What is your social worker's phone number?*What is the name of the clinic you attend?*Are you currently in treatment?*What is the estimated length of treatment?*Are there any additional ways we can help or do you have any questions?*Consent* I have read the information below and agreeBy checking the box above, you voluntarily accept help from Riley's Army Triangle Chapter and know that you can decline services at any time, as you are under no obligation to accept services or share personal information. You acknowledge that services are provided by volunteers and family liaison with approval from the board and understand that there are limitations to such services. You will provide 72 hours notice for financial support requests, and will agree to provide feedback and report any concerns about Riley's Army Triangle Chapter to the family liaison. You understand that Riley's Army reserves the right to decline services at any time.
