Cancer Support Community New Member Form

Welcome to CSC Greater Ann Arbor

Tell Us About You

Contact


Important Information About You (Bio UDFs)
* AA How would you like to receive our program calendar?
How did you hear about the CSC? (select all that apply)
If Other, please specify:
I am (check all that apply)
If other, please specify:
AA Type of cancer that you or your loved one has/had:
AA Treatment center where you/your loved one receive(d) care
AA Insurance
AA Employment Status
AA Marital Status
Do you have children under 18 in the home?
AA If children yes, name (s) & age (s)
AA Annual Household Income
AA Ethnicity
AA Sexual Orientation
Emergency Contact Name (Last, First)
ER Relationship With You
Emergency Contact Phone
Special Needs (if any):

Tell Us About The Programs Your Are Interested In
Select the ones that interest you the most
* Current Programs (select at least one)
Healthy Lifestyles
Living With Cancer Support Groups

Your comments are very important to us



It is Ok to contact me by Email
It is Ok to contact me by Mail
It is Ok to contact me by Phone
It is Ok to contact me for future donations





By submitting this webform you agree to CSC's confidentiality and safety policy related to CSC's virtual programs.

If you wish, take a moment to review Virtual Programs Confidentiality and Safety and close that window to continue.

 

Thank you for contacting the Cancer Support Community.  A member of our staff will be in touch shortly after we receive your information.

 

Your request will be processed. Do you want to continue?


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