Become A Member (GR)

A Cancer Support Community with Something for Everyone

From support groups and educational resources to mind-body classes and expressive arts workshops, our cancer support program is available to anyone impacted by cancer.

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Registration (JML)
Become A Member (GR)
BIO Member

Cancer Support Community New Member Form

(999) 999-9999?999

Welcome to Our House (Introduction)

Demographic information helps us understand who we are serving and any groups that may be underserved. Additionally, as a nonprofit, we must raise our budget anew every year. The majority of this funding comes from individual donors and grants. It is our obligation to report on the demographics of those accessing our services to these funders. All information is kept strictly confidential and is never linked to your name when used for reporting purposes.

* Indicates required information

* Your Last Name (Ignore)

* What is your connection to Cancer? (Ignore - use UDF)

Tell Us About You

We are here to help. Your information is safe with us. Your privacy is very important to us. Rest assured we will not share this information outside our organization.

Contact

Title

* First Name

Middle Name

* Last Name

* Gender

Date of Birth

Company / Division

Job Title

* Type of Email

* Email

* Type of Phone

* Phone

Type of Address

* Country

* Address

Street Apt/Suite/Unit/Other

* City

* State/Province

* Zip/Postal Code

County

Important Information About You (Bio UDFs)

Please complete the information below (notice some are mandatory)

*AA How would you like to receive our program calendar?

Mail and Email

Email Only

Do Not Send

How did you hear about the CSC? (select all that apply)

Doctor

Nurse

Social Worker or Therapist

Other Health Care Professional

Family/Friend

CSC Staff/Volunteer

Calendar/Brochure

TV/Radio

Other

If Other, please specify:

I am (check all that apply)

A person with cancer/survivor

A support person

Healthcare professional

Bereaved

Child of a loved one with cancer

Other

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

Medicaid

Medicare

Medicare + Private

Private

Uninsured

AA Marital Status

Single

Coupled

Domestic Partnership

Married

Divorced

Widowed

Do you have children under 18 in the home?

YES

AA If children yes, name (s) & age (s)

AA Annual Household Income

Under $25,000

$25,000-49,999

$50,000-74,999

AA Ethnicity

Hispanic/Latino

Non Hispanic/Latino

AA Sexual Orientation

Emergency Contact Name (Last, First)

ER Relationship With You

Family

Friend

Other

Emergency Contact Phone

Special Needs (if any):

Tell Us About The Programs Your Are Interested In (Activity UDFs)

We offer free virtual programs via Zoom and hybrid programs. Hybrid programs include the option to join either in-person or via Zoom.

We hope that you will explore some of our free programs, and please dont hesitate to give us a call if we can help support you.

You can reach Program Director at ###-###-####.

Click here to view programs currently available

Select the ones that interest you the most

* Current Programs (select at least one)

Weekly and Monthly Support Groups

Series Support Groups

Individual Support Groups

Education

Healthy Lifestyles

Social Events

Children, Teens and Family Programs

On Demand Programs

Cancer Support Help Line

Healthy Lifestyles

Cooking For Wellness In-Person (tag1)

Cooking For Wellness Virtual (tag2)

Evening Gentle Yoga In Person (tag3)

Evening Gentle Yoga Virtual (tag4)

Zumba Gold Virtual (tag5)

Living With Cancer Support Groups

Weekly Living with Cancer Group, Mondays 11 a.m.-1 p.m. (tag6)

Weekly Living with Cancer Group, Tuesdays 11 a.m.-1 p.m. (tag7)

Weekly Living with Cancer Group, Tuesdays 6-8 p.m. (tag8)

Your comments are very important to us

How did you hear about 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 our confidentiality and safety policy related to our programs and services.

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

Thank you for contacting us. 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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Cancer Support Community New Member Form

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