Connect Thru Cancer Client Registration Form
If you have any questions please 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.
Sign in to Google to save your progress. Learn more
Client Name *
Client Email *
Cell Phone *
Address  Street Name *needed for shipping books, cancer kits and busy bags when applicable, verify in-home support available and to track geographical reach of our programs. *
City
State
Zip
How did you hear about Connect Thru Cancer?
If you were referred by a Nurse Navigator or Social Worker, please let us know their name?
Out of State Residents: At this time we are offering specific workbooks for cancer patients, teens and kids that can be mailed to you. We can also send a list of additional resources available to help you navigate the treatment process.
Emergency Contact/Spouse *
Cancer Diagnosis *
Stage
Treatment (check all that apply) *
Required
Are you currently in treatment? *
If no what is the date of your last treatment?
What Hospital/ Cancer Center are you receiving treatment? *
Did you receive a Cancer Comfort Kit from your hospital system or Nurse Navigator/Social Worker?
Clear selection
What is the name of your Oncologist?
Client Age *
Number of Children: Name, Gender, Age (Helps with resources appropriate for them) *
I am interested in learning about your in-home program (Offered weekly for 1.5 hours/week to provide creative play with young kids at home and respite to the parent) *Currently offered to the Tri-County Philadelphia Area: Chester, Delaware and Montgomery County *
For In Home Program:  Child Name  | Age  | Gender  | Special Concerns *
For In Home Program:  Child Name  | Age  | Gender  | Special Concerns *
For In Home Program:  Child Name  | Age  | Gender  | Special Concerns
Household Income: *
Ethnicity *
Would you like a phone call to learn more about our in-person programs? Specifically our in-home support programs and monthly family fun days? *
Please tell about what type of support you need most. If we do not provide that we can try to send you resources that may help. *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy