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.
Client Name *
Client Email *
Address (Street, City, State, Zip) *needed for shipping books, cancer kits and busy bags when applicable and to track geographical reach of our programs. *
City
State
Zip
Home Phone
Cell Phone
Other Emergency Contact *
Spouse/Caregiver Name
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? *
What is the name of your Oncologist?
Client Age *
Child Name | Age | M/F | Special Concerns *
Child Name | Age | M/F | Special Concerns *
Child Name | Age | M/F | Special Concerns *
Child Name | Age | M/F | Special Concerns *
Household Income: *
Ethnicity *
Out of State Residents: Programs Available ( Please check those you are interested in)
Notes: Please send us any additional information that will help us to provide the best support program.
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy