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
Client Name *
Your answer
Client Email *
Your answer
Address
Your answer
Home Phone
Your answer
Cell Phone
Your answer
Spouse/Caregiver Name
Your answer
Cancer Diagnosis
Your answer
Stage
Your answer
Treatment (check all that apply) *
Required
Are you currently in treatment? *
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 *
Child's Name | Age | M/F | Special Concerns *
Your answer
Child's Name | Age | M/F | Special Concerns
Your answer
Child's Name | Age | M/F | Special Concerns
Your answer
Child's Name | Age | M/F | Special Concerns
Your answer
Child's Name | Age | M/F | Special Concerns
Your answer
Household Income: *
Ethnicity *
Out Of State Residents: Programs Available ( Please check all that apply)
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