Support Person 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* This field is required.
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 the following benefits?* This field is required.
SNAP, Food Stamps
TANF, Cash Assistance
Medicaid
Social Security Insurance
N/A
PACE or PACE-NET
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
If no, when was your last treatment?
15
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
16
Please tell us the name of the person you're supporting:* This field is required.
17
How is this person related to you?* This field is required.
Parent
Grandparent
Spouse/Partner
Sibling
Child
Friend
Relative
Other
18
What is their cancer diagnosis?* This field is required.
19
Is this person part of our ECWC community at this time?* This field is required.
Yes, they are a participant.
No. They are not a participant, but they ARE interested in joining.
No. They are not a participant, and they ARE NOT interested in joining.
I don't know/unsure
20
What is your primary wellness goal?
Physical Activity
Nutrition Guidance
Social Connection
Emotional Support
Stress Management
unsure
Other
21
What programs interest you?
Support Groups
Movement Classes
Meditation/Mindfulness
Journaling
Art Therapy
Nutrition Education
Educational Workshops
Other
22
Preferred Program Times
Weekday AM
Weekday Afternoons
Weekday PM
Saturday
Sunday
Unsure
23
The ECWC has a Support Person Group which meets once a month on the first Thursday at 4:00 p.m. If interested, please register on our Program Calendar. In addition, you are welcome to attend any activities which are listed on our program calendar, with the exception of reiki and oncology massage. All our services are free of charge.* This field is required.
I'm interested in attending the support group in person or virtually.
I'm interested in attending the support group but I'm unavailable during that day/time.
I'm not interested in attending the support.
I'm not sure yet.
24
If yes, please specify.
Psychologist
Psychiatrist
Therapist/Counselor
Other
25
Transportation Needs:
I can arrange my own transportation.
I need assistance with transportation- (ECWC May be able to provide support in the future.)
I am interested in Virtual Options
26
Emergency Contact Name and Relationship
27
Emergency Contact Phone Number
28
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.
29
Signature
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30
Consent and Release:

By submitting this form to the ECWC, I understand the following:

·         I/we represent that the activities that I/we register for will be those that are appropriate for our physical condition and if they become beyond our abilities, I/we will ask for a modification or stop the activity.

·         Our participation in all classes or services is voluntary and I/we consent to participate.

·         I/we 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/our participation in classes/services.

·         I/we hereby release and discharge ECWC from all liability arising out of or in connection with the class(es) and/or services.

·         I/we understand that I/we are solely responsible for any loss or injury suffered by me, my child or my property resulting from our participation in classes/services.

I/we understand that the employees and providers of the ECWC are mandated reporters and are required to report any suspected abuse/neglect to the authorities
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