Cancer Pathways Interest Form

All Cancer Pathways programs and support services are completely free. Please note, we do not offer medical advice or make medical oncology referrals.

You can expect a response from a Cancer Pathways staff member in 2-3 business days.

Contact Information

Name

First Name

Last Name

Please select all that apply

I have/had...

cancer

a parent with cancer

a child with cancer

a loved one with cancer

I am a medical provider

I am a community supporter

Other

Please describe:

Phone Number

Verify Email

City

State

County

Date of Birth

(mm/dd/yyyy)

Gender

Male

Female

Gender Non-binary

Other

Are you of Hispanic, Latino, or Spanish origin?

Yes

Race

Please choose the option(s) that represent you best

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or Other Pacific Islander

White

Other

Please describe:

Emergency Contact

First Name

Last Name

Emergency Contact Phone Number

Emergency Contact Relationship

Program and Support Services Interest

Which programs are you interested in?

Youth and Family Program (Camp Sparkle, Sparkle Saturdays)

Writing Contest for Teens (Cancer Unwrapped)

Teen Ambassador Program

Middle and High School Education Program (Cancer Happens)

Workplace Networking Group

Presentations and Classes (cancer education, clinical support, nutrition, complementary and alternative medicine, etc.)

Which support services are you interested in?

A 30 minute emotional support session with a licensed social worker

Bereavement Group

Caregiver Group

Living with Cancer Support Group

Lung Cancer Group

Parents Living with Cancer Group

Parent Grief Group

Survivorship Group

Therapeutic Art Group

Are there any other topics, classes or information you'd like to learn more about?

How did you hear about Cancer Pathways?

Internet search

Word of mouth

From Medical Provider/Nurse/Social Worker

Cancer Pathways website

Social Media

Other

May we send you the quarterly Cancer Pathways newsletter?

Yes

Cancer Pathways collects the above personal information for the purpose of member registration. This information will be kept confidential and will not be shared or sold to any outside organizations, groups or individuals. By completing this form, you consent to the collection of this information by Cancer Pathways. You may request to review this information or have it deleted at any time.

Today's Date

(mm/dd/yyyy)

Electronic Signature