Connect Thru Cancer Client Registration Form
Once you have completed this form and have registered, you will receive a phone call from one of our coordinators to discuss our support programs. (New client phone calls are typically made on Mondays) or contact us by email at
info@connectthrucancer.org
. Please note: This organization provides programs of support to cancer patients and their families. We do not provide financial assistance.
* Required
Client Name
*
Your answer
Client Email
*
Your answer
Address (Street, City, State, Zip) *needed for shipping books, cancer kits and busy bags when applicable and to track geographical reach of our programs.
*
Your answer
City
Your answer
State
Your answer
Zip
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Other Emergency Contact
*
Your answer
Spouse/Caregiver Name
Your answer
Cancer Diagnosis
Your answer
Stage
Your answer
Treatment (check all that apply)
*
Surgery
Chemotherapy
Oral Chemotherapy
Radiation
Immunotherapy
Targeted Therapy
Hormone Therapy
Stem Cell Transplant
Precision Medicine
Required
Are you currently in treatment?
*
Yes
No
If no what is the date of your last treatment?
Your answer
What Hospital/ Cancer Center are you receiving treatment?
*
Your answer
What is the name of your Oncologist?
Your answer
Client Age
*
20-30
30-40
40-50
50-60
60+
Child Name | Age | M/F | Special Concerns
*
Your answer
Child Name | Age | M/F | Special Concerns
*
Your answer
Child Name | Age | M/F | Special Concerns
*
Your answer
Child Name | Age | M/F | Special Concerns
*
Your answer
Household Income:
*
$10,000-$30,000
$31,000-$50,000
$51,000-$80,000
$81,000-$100,00
> $100,000
Ethnicity
*
White/Caucasian
Black or African American
Hispanic/Latino
American Indian or Alaska Native
Asian
Other
Out of State Residents: Programs Available ( Please check those you are interested in)
Cancer Comfort Kits
Busy Bags
Educational Resources
Virtual Programs
Notes: Please send us any additional information that will help us to provide the best support program.
Your answer
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