Referral Form for Clients | Cancer Society Wellington

Support Registration Form
We support anyone affected by cancer –patients, whānau, family, friends and colleagues. We can help you, or someone you care about, understand about cancer, how to talk with others, and find the support most suitable for you.
Fill out our Support Registration Form
Your Name *

First NameLast Name
Are you a*

PatientSpouse/PartnerWhānau/FamilyOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Email*
example@example.com
Your Phone / Mobile*
What would you like us to know about you?

What information would you like to receive?
I would like to be contacted by the Support Coordinator*

YesNo
I would like to receive information regarding support groups and events*

YesNo
I am happy to receive the occasional email or newsletter about local events or information*

YesNo

Privacy Permission

Your information and records of any support received from the Cancer Society, will be kept on our secure database in accordance with the Privacy Act. We do not share your information unless we have your consent to do so for a specific purpose.
Type a question*

Yes - I understand my information and records will be stored by the Cancer Society
Today's Date*

DayMonthYear
Date
Should be Empty:

Support Registration Form