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
2 digit month, 2 digit day, 4 digit yearDate
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

City & StateState / Province

Zip Code
Phone Number
Format: (000) 000-0000.
Is this a home or cell number?
Email Address
example@example.com
Gender Identity
If not listed, my gender is:
Sexual Orientation
If not listed, my sexual orientation is:
Preferred Pronouns
Which of the following best represents your racial or ethnic heritage
Employment Status
Do you have children between the ages of 5 and 18?
If yes, what ages?
I am registering as
Where do you receive Oncology care?
Do you wish to receive the calendar in Spanish?
Emergency Contact Information:
Name
Relationship
Emergency Contact Cell Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Home / Alternate Number
Please enter a valid phone number.Format: (000) 000-0000.
Please Complete the following about yourself or the person you are here to support:
Cancer Type
Date of Diagnosis

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Oncologist Name
Should be Empty:

Annual Participant Form