Thank you for your interest in joining (or referring someone to join) Gilda’s Club Kentuckiana! After you have completed this form, the interested member will receive 1-2 emailed forms from us for completion (bereaved members will receive 1, caregivers and those living with cancer will receive 2). Once those emailed forms have been completed, the interested member will receive a call from a social worker to talk more about their story and connect them to appropriate support groups and other program offerings. Please note our system does not support shared email addresses - if you do not have your own email address, please type “none” and we will call you to complete the process. Questions? Please contact us at 502.583.0075 or GCKinfo@gck.org.
Please note, Gilda's Club Kentuckiana will be closed starting Friday, Feb. 23rd at 2pm, and will reopen on Monday, March 4th at 9am. Forms completed during this time will be sent upon our return in March.
Full name of person making the referral
Contact information of person making the referral (if not self)
Full name of interested member
Phone number of interested member
Please enter a valid phone number.
Email address of interested member (if none or using a shared email, type "none")
This person is
person with cancer
Date of birth of interested member
Primary language of interested member
Notes or any further information that we should know
Patient Confidentiality Agreement
To ensure patient privacy protection as part of the Health Insurance Portability and Accountability Act (HIPAA), and to provide patients with control over what personal information is used and disclosed, I agree to have the above information released to Gilda’s Club Kentuckiana or agree the person I am completing the form for has given me permission to release this information on their behalf. I understand this form is HIPAA-compliant, and my/their information will then be added to Gilda's Club Kentuckiana's database.
Should be Empty: