Cancer Pathways Support Group and Program 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. This form is for anyone 18+. If you are interested in teen support services, please fill out this form: https://airtable.com/appJsUGxnNcVcABgI/shrNpsbqrrDmTqRzb You can expect a response from a Cancer Pathways staff member in 2-3 business days. Interested in volunteering? Please fill out our form at: https://airtable.com/shrprRQszudrbRvTy

First Name

Last Name

Please select all that apply.

I have/ had...

Phone Number

Street Address

City

State

Zip Code

Date of Birth

Gender

Please choose the option(s) that represent you best

Select an option

Pronouns

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Race/Ethnicity

Please choose the option(s) that represent you best

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Have you participated in a support group with Cancer Pathways before?

Which Support Groups are you interested in?

These are facilitated by our licensed professionals. Group descriptions and meeting times can be found here: https://cancerpathways.org/programs/support-groups/ *Please note all are virtual except for the one listed as "In person: Living with Cancer"

What community and wellness groups are you interested in?

Topics of interest:

Select all that apply. These topics may be used in future workshops, classes, or podcast episodes.

Anything else you'd like us to know?

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Emergency Contact Name

First and Last

Emergency Contact Phone Number

Emergency Contact Relationship

How did you hear about us?

Select an option

I'm interested in sharing my story or expertise with the Cancer Pathways community

Ex: podcast guest, Quit Tobacco facilitator, workshop host

Yes
No
Please contact me, I'd like more information

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. By signing up, you will receive periodic updates and communications from Cancer Pathways. You may unsubscribe at any time.

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