CSC New Participant Form

New Participant Form

...so that no one faces cancer alone.
All programs and services are offered at no charge to cancer patients and their loved ones. This is made possible by the generous donations of our participants, other individuals, and grants. We are not affiliated with any insurance company and we do not receive Federal or State funding. Please complete all parts of this form. The information helps us know who we serve, track needs, and understand how people are referred to us. As a nonprofit organization, information about who we serve (in statistical form only, never about an individual) is critical to ensuring continued funding. No identifying information is shared outside of CSC. Thank you!
Today's Date:

MonthDayYear
Preferred Title:

Mr.Mrs.MissMs.Other
Name:*

First NameLast Name
Street Address:
City:*
State:*
Zip Code:*
Are you currently residing in California?*

YesNo
Email:
example@example.com
Phone (Home):
Phone (Mobile):
Date of Birth:*

MonthDayYear
I am a:*

Cancer Patient or SurvivorCaregiver/Loved oneExperienced the recent death of a cancer patient
Cancer Patient's Treating Hospital (indicate N/A as needed):*
Hospital (indicate N/A as needed):*
How did you learn about Cancer Support Community Pasadena? (check all that apply)*

FamilyFriendInternet searchSocial Media (specify)Event (specify)Print/Online Advertisement (specify)CSC Calendar (where did you see it?)Physician (specify)Nurse (specify)Social Worker (specify)Therapist (specify)Other Healthcare Professional (specify)
Specific Referral Source:
What services are you interested in learning more about?

Support GroupsEducational WorkshopsHealthy Lifestyle ClassesSocial EventsResources and ReferralsOther
Would you like to receive our weekly program line-up by email?

YesNo
Would you like to receive our printed quarterly paper calendar in the mail?

YesNo
I identify as:*

ManWomanTransgender ManTransgender WomanNon-binaryPrefer not to answerOther
Marital Status:

SingleMarriedPartneredSeparatedDivorcedWidowed
Sexual Orientation:*

StraightLesbianGayBisexualOtherPrefer not to answer
Do you have any children between the ages of 5 and 18?

YesNo
If yes, what age(s)?
Type of Cancer:
Date of Diagnosis:

MonthDayYear
Doctor/Oncologist:
Loved One's Name:
Loved One's Cancer:
Date of Passing:
Cancer Patient's Name:
Cancer Patient's Diagnosis:
Several of our funding and accrediting agencies require us to ask for the following demographic information. The following information will be used for statistical purposes only and is not linked to your name.
Ethnic Background:

White (not Hispanic)Latino/HispanicAmerican IndianAsian/Pacific IslanderAfrican American/Black (Non-Hispanic)African American/Black (Hispanic)Other
Number in Household:
Annual Family Income:

Under $25,000$25,000-$49,999$50,000-$74,999$75,000-$99,000Over $100,000
Insurance Status:

MedicareMedi-Cal/MedicaidPrivate InsuranceUninsured
Employment Status:

Full Time:Part TimeOn Medical LeaveDisabledNot EmployedRetired
Emergency Contact:
Relationship:
Emergency Contact Phone:

Area CodePhone Number
Policies

Confidentiality

Our staff and volunteers respect the privacy of our participants. Cancer Support Community San Gabriel Valley (CSC) adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.

CSC asks that our participants respect each other’s privacy and do not disclose the identity of others who participate at CSC, or what is personally shared in a CSC program. However, we are not able to ensure confidentiality of all participants, as we would have no way to enforce it.

Consent Statement

By signing this document, I:
- Understand that CSC and program partners recommend that anyone participating in any exercise program check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any exercise program could result in injury or illness.
- Release, waive, discharge and hold harmless CSC and its program partners, affiliates, employees, officers, agents, independent contractors, volunteers and donors from any and all claims, actions, demands, liabilities, expenses (including attorneys’ fees) and losses arising from bodily injury or illness, including, but not limited to, wrongful death, loss of services, loss of consortium, and all other damages that may arise out of participation in an exercise or healthy lifestyle program.
- Authorize the use of the videoconferencing platform, Zoom, for the provision of and participation in distance-oriented programs.
Signature*

Clear
Should be Empty: