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!
Email address *
Full Name *
Your answer
Contact Phone Number *
Your answer
When is it best to contact you? *
Your answer
Emergency contact name and phone number *
Your answer
Residence Address *
Your answer
Residing County *
Your answer
Which best describes you? *
Required
Type of Cancer *
Your answer
Type of Treatment. Select all that apply. *
Required
Provide the name of your treating physician. *
Your answer
Select all programs you are interested in? *
Required
If there is a program you would like to see that we do not offer, please let us know.
Your answer
How did you hear about Journey to be FREE? *
Your answer
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. *
Required
Income Level *
Gender *
Age *
Your answer
Ethnicity *
Your answer
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 cathy@cancersupportwnc.org. 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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