New Member Registration
Please answer the following questions prior to participating in Young Adult Survivors United programs. This information will be kept confidential and will not be shared with anyone.
Today's Date *
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First Name *
Last Name *
Street Address *
City *
State *
Zip Code *
For residents in Western PA, which county do you reside in? *
For residents outside of Western PA, which county and state do you live in? (please list both) *
Race: *
How would you describe your gender? *
Ethnicity: *
Email address *
Primary phone number *
Date of birth (mm/dd/yyyy) *
Which of the following best describes you? (Check all that apply) *
If you are a co-survivor, what is the name of the young adult survivor you're caring for? (first and last name). This information will be kept confidential and will not be shared with anyone. (Please enter n/a if this question does not apply to you.) *
Which YASU program(s) are you interested in? All programs are currently hosted virtually until further notice. (Check all that apply) *
Required
Type of cancer diagnosis (and stage if applicable) *
Date of diagnosis (mm/yyyy) *
Hospital affiliation *
Marital status *
Number of household members (including you) *
How many children under 18 years old live in your household? *
Any history of a Mental Health disorder? (Check all that apply) *
Required
Are you on Mental Health medications? (Check all that apply) *
Required
How did you hear about Young Adult Survivors United? *
Required
Want to join our email list? *
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