CSC Participant Form

Annual Participant Form
The Cancer Support Community (CSC) gathers information to help us better understand who comes to our programs; with the intention to increase our ability to address the needs of all groups. Your answers to these questions will, in no way, affect your ability to access all programs at the CSC and at no charge. Thank you.

All personal information will be kept CONFIDENTIAL.
Date

MonthDayYear
Date
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City & StateState / Province

Zip Code
Phone Number*
Is this a home or cell number?

HomeCell
Email Address*
example@example.com
Gender Identity

Woman (includes Transwoman)Man (Includes Transman)Non - binaryMy gender not listed
If not listed, my gender is:
Sexual Orientation

GayLesbianStraightAsexualBisexualMy orientation is not listed
If not listed, my sexual orientation is:
Preferred Pronouns
Which of the following best represents your racial or ethnic heritage

White Non-HispanicBlack, African American, or Afro-CaribbeanLatino, Hispanic, SpanishEast Asian, or Asian AmericanSouth Asian or Indian AmericanIndigenous American or Alaskan NativeMiddle Eastern or Arab AmericanOther
Employment Status

EmployedOn Medical LeaveRetiredDisabled
Do you have children between the ages of 5 and 18?

YesNo
If yes, what ages?
I am registering as

Person who has been diagnosed with cancerCaregiverSupport PersonHealthcare ProfessionalOther
Preference to Receive the CSC calendar

EmailPostal MailBoth
Do you wish to receive the calendar in Spanish?
Emergency Contact Information:
Name
Relationship
Emergency Contact Cell Number
Please enter a valid phone number.
Emergency Contact Home / Alternate Number
Please enter a valid phone number.
Please Complete the following about yourself or the person you are here to support:
Cancer Type
Date of Diagnosis

MonthDayYear
Date
Oncologist Name
Should be Empty:

Annual Participant Form