Canadian DIPG mapping
Please fill in the entire form. This information will not used for any other purpose than research and mapping of DIPG/children's brain cancer.
The name of the person filling in the form
Your relationship to the child
Son daughter relative friend
Name of child with DIPG (optional)
Sex of child with DIPG/brain cancer (this is important for research purposes)
Birth date of child with DIPG/brain cancer.
Postal code of residence at time of diagnoses.
Month and year of death (if applicable)
Type of brain cancer
Sub type of DIPG if known from biopsy
Permission to contact you for more information, if a research project requires it.
I give my permission