Full Member
1. Patients and survivors of the Children’s Cancer Centre in PWH as well as their parents are eligible to apply.
2. Members aged of 18 or above 18 can have the right to vote and be elected.

Associate Member*
1. Siblings of patients and survivors are eligible to apply.
2. Anyone or any institutions that are interested in or have contribution to LLWS.
*Cannot enjoy the right to vote and be elected.


Fields marked with a are required


Details of Patient / Survivor:
Name(English):
Name(Chinese):
Gender :
Date of birth
(day/month/year):
Date of Diagnosis
(day/month/year):
Diagnosis:
Hospital where you are under: Prince of Wales Hospital
Princess Margaret Hospital
Queen Elizabeth Hospital
Tuen Mun Hospital
Queen Mary Hospital
Other
Phone (home):
(Mobile):
E-mail:
Address:



Father/Mother/Guadian Information
Relationship:
Name(English):
Name(Chinese):
Gender :
Date of birth
(day/month/year):
Occupation:
Phone (home):
(Mobile):
E-mail:
Address: live together

Father/Mother/Guadian Information
Relationship:
Name(English):
Name(Chinese):
Gender :
Date of birth
(day/month/year):
Occupation:
Phone (home):
(Mobile):
E-mail:
Address: live together

Details of other family members (Associate Members):

Associate Members1
Name:
Relationship:
Gender :
Date of birth
(day/month/year):


Associate Members2
Name:
Relationship:
Gender :
Date of birth
(day/month/year):


Associate Members3
Name:
Relationship:
Gender :
Date of birth
(day/month/year):

Privacy Policy Statement: The information provided is only for LLWS’s internal use. Members agree that LLWS has the right to use any photos and images taken in the activities that the members participate in.