Cancer Participant Form

1
Have you filled out a participant form in the past?
YESNO
2
Name* This field is required.
First Name
Last Name
3
Address* This field is required.
4
Mobile Phone* This field is required.
5
Home Phone
6
Are you a Veteran? If so, please indicate branch.* This field is required.
7
Email* This field is required.
example@example.com
8
Do you receive SNAP, Medicaid, Cash Assistance, SSI, PACE or PACE-NET benefits?* This field is required.
Yes
No
9
Date of Birth* This field is required.
Date
Month
Day
Year
10
How would you prefer to be contacted?* This field is required.
Text
Phone call
Email
11
Gender* This field is required.
12
Marital Status* This field is required.
13
Occupation* This field is required.
14
Type of PRIMARY cancer* This field is required.
15
Date of PRIMARY diagnosis* This field is required.
Date
Month
Day
Year
16
Have you been diagnosed with Metastatic/State 4 Cancer?* This field is required.
Yes
No
Unsure
17
Are you currently receiving treatment?* This field is required.
Yes
No
18
If no, when was your last treatment?
19
How did you hear about the ECWC?* This field is required.
AHN Saint Vincent
AHN Saint Vincent Cancer Institute
LECOM/Millcreek Community Hospital
LECOM/Corry Memorial Hospital
UPMC Hamot UPMC Hillman Cancer Center/Erie
UPMC Children's Hospital/Pittsburgh
Cleveland Clinic
Yolanda G. Barco Oncology Institute/Meadville
Media-TV
Radio
Newspaper
Social Media
Other
20
What is/was the treatment plan?* This field is required.
Chemo
Radiation
Surgery
Immunotherapy
Alternative Medicine
Other
21
Please provide the name/position of the person that referred you to us:* This field is required.
22
Is there something specifically you are looking for here at the ECWC (ie. wig support group nutrition etc.)* This field is required.
23
What is your primary wellness goal?
Physical Activity
Emotional Suppoirt
Social Connection
Stress Management
Nutrition Guidance
Unsure
Other
24
Which programs interest you?
Support Groups
Movement Classes
Meditation/Mindfulness
Nutrition Education
Art Therapy
Educational Workshops
Reiki
Massage
Wig Salon
Journaling
25
Preferred Program Times
Weekday AM
Weekday Afternoons
Weekday PM
Saturday
Sunday
unsure
26
Transportation Needs:
I can arrange my own transportation.
I need assistance with transportation-(ECWC May be able to provide in future)
I am interested in virtual options.
27
Who is in your support system?* This field is required.
28
Do you have a history of :
Depression?
Anxiety?
Substance Abuse?
None of the above
29
Are you followed by a mental health professional?* This field is required.
Yes
No
30
If yes, please specify.
Psychologist
Psychiatrist
Therapist/Counselor
Other
31
Emergency Contact Name and Relationship* This field is required.
32
Emergency Contact Phone Number* This field is required.
33
Photo Waiver: We want the community to see the great things we're doing at the ECWC. This will sometimes require pictures to be taken while classes are in session. Please sign below if we have your approval to take pictures where your face may or may not be visible.
34
Signature
Clear
35
Consent and Release: I understand the following:

It is my responsibility to clear my participation at the ECWC with my physician if I am receiving care. I represent that the activities I register for will be those that are appropriate for my physical condition and if they become beyond my abilities, I will ask for a modification or stop the activity. My participation in all classes or services is voluntary and I consent to participate; I agree to hold Erie Cancer Wellness Center class(es) and/or its services, its directors, officers, employees and agents harmless from all liability and claims arising out of or in connection with my participation in classes/services. I hereby release and discharge ECWC from all liability arising out of or in connection with the class(es) and/or services. I understand that I am solely responsible for any loss or injury suffered by me or my property resulting from my participation in classes/services.
36
Signature* This field is required.
Clear
37
Type a question
YESNO
Should be Empty: