Cancer Buddy Program Volunteer Registration
Thank you for your interest in volunteering!
Name
*
First Name
Last Name
Phone Number
*
Format: (000) 000-0000.
Email
Confirmation Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Have you been in remission for at least one year?
*
Yes
No
I will be soon.
If you have not been in remission for at least a year, when will you be?
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About You
Your responses will help us match you with a Buddy.
Gender
*
E.g. Non-conforming, non-binary, woman, man
Preferred Pronouns
*
E.g. She/Her/Hers, They/Their, Them
Marital Status
*
Please Select
Single
Married
Divorced
Separated
Other
Do you have children?
*
What was the primary cancer you battled?
*
E.g. Skin, breast, colon, brain tumor, etc.
If applicable, indicate secondary cancer.
What was your treatment type?
*
E.g. Radiation oncology, chemotherapy, surgery, etc.
Preferred Form of Communication with Buddy
*
Rows
Yes
Open, but not preferred
No
In-Person
Phone/FaceTime
Zoom
How did you learn about our Cancer Buddy Program?
*
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