ALK Positive Registration Form
This is our closed support group registration form. The group is made up of patients who have ALK-positive lung cancer, and/or caregivers of ALK-positive lung cancer patients.

All Patients (or their Caregivers) must complete this form prior to being accepted into the group. This is to protect the privacy of our members and ensure only real patients and/or their caregivers are in the group. Once in the group if you wish to add other loved ones or family members, you may do so, but each patient (or their caregiver) must complete this form. The Administrators

We will not share your information with anyone without your express consent. However, since this is a support group on the Facebook platform, your information may be used by Facebook in accordance with their Terms of Service and Privacy Policies. Anything posted to the group by you, or posts that you are tagged in, will not be visible to anyone who is not a member of the group. Postings from the group that appear on your news feed is only seen by you. Your membership in the group is private.

Upon submission of this form and approval for you to join the group, a Moderator will post a welcome message to you (they will tag you in the message) along with this profile sheet to the group.

We ask that you provide an introduction of yourself within one week. This facilitates your acceptance into the group and allows current members to welcome you and to connect with you. It will enhance your overall experience within the group. You will see very quickly it is a very active, supportive, and social group.

Email address *
Your Facebook Name *
You can find this by going to your Facebook profile in a web browser and looking at your web browser address bar. Your profile name will be after the Facebook address (i.e.
Your answer
Personal Information
First Name *
Your answer
Last Name *
Your answer
Where do you live? *
Please provide the city/town, state/province, and country. This will help those who are close to you to connect with you.
Your answer
Are you the patient or caregiver? *
Only one person (patient or caregiver) should fill out this form regardless of the answer.
If you are the caregiver, what is the patient's name?
Your answer
How did you learn of our ALK Positive Community? *
Medical History
This information is collected voluntarily. Please provide as much detail as you feel comfortable. The more details you provide will help you to connect with those who are similar to you in past and current treatments. Also, by providing these details other members may be able to provide you with information and support.
What was the date of the initial lung cancer diagnosis? *
What type of ALK-positive lung cancer? *
What stage at diagnosis? *
What is the current stage of lung cancer? *
Age at time of diagnosis? *
Your answer
What is the name of the primary facility that is treating the ALK-positive lung cancer? *
Your answer
What is the name of the primary oncologist who is treating the ALK-positive lung cancer? *
Your answer
What was the primary career field/profession when diagnosed? *
Your answer
Which medication are you taking now? *
What treatments have been received previously? *
Has the patient ever had a brain MRI with and without contrast? *
Do you have anything else you would like to tell us, or comment about?
Your answer
Do not forget to go to and click the JOIN GROUP button on our page. We cannot process your request if you do not request to join the group.
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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