GCT Membership Application

Membership Application

If you have any questions or problems completing this form, please email GCT Support at support@GCTSupport.org. An asterisk (*) denotes fields that are required to submit this form.
All information provided will be kept strictly confidential and is for GCT Support only. We are committed to protecting the privacy of our members. Any data or information that we share in any way is de-identified to protect confidentiality. GCT Support is a program of The Life Raft Group.
Today's Date

MonthDayYear
Date
Name*

First NameLast Name
I am a:*
If other, please specify:*
Patient Name*

First NameLast Name
The patient is my:*
If 'other' please specify:*
I am interested in:

Fundraising ActivitiesBeing matched with a Mentor (Mentors support GCT patients through their journey).VounteeringSupport GroupsOther
Where is your disease located?*
How did you hear about GCT Support? Choose all that apply.

Another GCT memberThe GCT Facebook pagesInternet searchDoctorOther
If 'other', please specify:*
If 'other', please specify
Email Address*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
US Country code is 1. Look up country codes here.
This phone number is my:*
Preferred Method of Contact*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country*
WhatsApp Number
Skype ID
Preferred Time to Contact*
Please indicate time zone*
Please verify that you are human*
Should be Empty: