Program Participant Registration
Welcome to Journey to be FREE. Thank you for your interest in our programs. To help us best serve you, kindly complete this registration form. All personal information is kept confidential. Thank you!
Contact Phone Number
When is it best to contact you?
Emergency contact name and phone number
Which best describes you?
Recently diagnosed with cancer
Currently in cancer treatment
Completed treatment less than 12 months ago
Completed treatment between 12 months and 24 months ago
Completed treatment between two years and five years ago
Long-term cancer survivor (completed treatment beyond five years ago)
Spouse/Partner of someone diagnosed with cancer
Parent of someone diagnosed with cancer
Child of someone diagnosed with cancer
Family member of someone diagnosed with cancer
Friend of someone diagnosed with cancer
Loss of a loved one
Type of Cancer
Type of Treatment. Select all that apply.
biological therapy (immunotherapy)
complementary or alternative therapies
Not known as this time
Provide the name of your treating physician.
Select all programs you are interested in?
Cancer Networking Group - monthly networking group
The Healthy Kitchen - monthly nutrition education
From Surviving Cancer to Thriving in Life - monthly post-treatment program
The Wellness Connection - monthly healthy living workshop
A Day to be FREE: Wellness Retreat
Annual Weekend Retreat for Women
Social Connection - periodic social gatherings
journey hOMe: restore wellness - weekly mindful movement program
Horses Help Heal Cancer Survivors - private sessions
Cancer Transitions: Moving Beyond Treatment - Five-Week Post-Treatment Session
If there is a program you would like to see that we do not offer, please let us know.
How did you hear about Journey to be FREE?
Information for Statistical Purposes Only
Thank you for providing this information as we provide programs and services at no cost to you through grants, program sponsors and individual donations. This information is used for statistical purposes only. Your individual information will remain confidential and never be released.
Health Coverage. Check all that apply.
No healthcare coverage
Applying for health insurance
$0 - $14,999
$15,000 - $29,000
$30,000 - $44,999
$45,000 - $59,000
May we add you to our email list to receive a quarterly newsletter and/or program updates?
Thank you for completing this Program Participant Registration
If you have any questions, please do not hesitate to contact Catherine Desfosses, Executive Director, at 828-771-0885 or via email
. A member of the Journey to be FREE support team will contact you.
A copy of your responses will be emailed to the address you provided.
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