Participant Information Form

Cancer Support Community gathers information about every participant to help us communicate and provide effective programming for cancer survivors and their loved ones.  All personal information is kept confidential and only shared with your permission.

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How did you hear about us?
Direct Referral Person
Please select the role that best represents you at this time
Name of Cancer Patient you are Supporting
Primary Cancer Type
Stage (if known)
Date Diagnosed
v
Date Bereaved
v
Oncologist
Medical Center
Provide name and date of birth of child(ren)
0/1000 characters

The information below helps CSC provide programming and support that meets the needs of cancer survivors and their families.

Sexual Orientation
Ethnicity
If AI/AN, name of Tribe
List 1st or 2nd degree AI/AN, name of Tribe
Type of Employment
Insurance
Marital Status
Veteran Status
Emergency Contact Information
Contact Name
Relationship
Home Phone
Work Phone
Cell Phone


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