Clone of Cancer Participant Form

Have you filled out a participant form in the past?* This field is required.

YESNO

Name* This field is required.

First Name

Last Name

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Mobile Phone* This field is required.

Date of Birth* This field is required.

Date

Email* This field is required.

example@example.com

Are you a military veteran?

YESNO

If you are a military veteran, please indicate your branch of service.

Army

Navy

Air Force

Marine Corps

Space Force

Coast Guard

How would you prefer to be contacted?* This field is required.

Text;

Phone call;

Email;

Gender* This field is required.

Male

Female

Nonbinary

Not Listed

Which category below fits your background best?* This field is required.

White or Caucasian

Asian

Native Hawaiian or Pacific Islander

Hispanic or Latino

African-American

Native American

Two or more

Unknown

I'd prefer not to say

Other

Marital Status* This field is required.

Single (never married)

Married

Divorced

Widowed

Legally Separated

Other

Occupation* This field is required.

Type of PRIMARY cancer* This field is required.

Date of PRIMARY diagnosis* This field is required.

Date

Have you been diagnosed with Metastatic/Stage 4 Cancer?* This field is required.

Yes

Unsure

Are you currently receiving treatment?* This field is required.

Yes

If no, when was your last treatment?

Date

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 Hillman Cancer Center/Erie;

UPMC Children's Hospital/Pittsburgh;

Cleveland Clinic;

Barco Oncology Institute/Meadville;

Media-TV;

Radio;

Newspaper;

Social Media;

UPMC Hamot;

VA Medical Center;

Friend/Family;

What is/was the treatment plan?* This field is required.

Chemotherapy;

Radiation;

Surgery;

Immunotherapy;

Alternative Medicine;

Other;

Do you receive SNAP, Medicaid, Cash Assistance, PACE or PACE-NET benefits?* This field is required.

Yes

Do you have medical insurance?* This field is required.

Yes

If yes, who is your insurance provider?

Please provide the name/position of the person that referred you to us:* This field is required.

Is there something specifically you are looking for here at the ECWC (ie. wig, support group, nutrition, etc.)* This field is required.

What is your primary wellness goal?

Physical Activity;

Emotional Suppoirt;

Social Connection;

Stress Management;

Nutrition Guidance;

Unsure;

Other;

Which programs interest you?

Support Groups;

Movement Classes;

Meditation/Mindfulness;

Nutrition Education;

Art Therapy;

Educational Workshops;

Reiki;

Massage;

Wig Salon;

Journaling;

Preferred Program Times

Weekday AM;

Weekday Afternoons;

Weekday PM;

Saturday;

Sunday;

Transportation Needs:

I can arrange my own transportation;

I need assistance. (Possible in future);

I am interested in virtual options;

Who is in your support system?* This field is required.

Do you have a history of any of the following?* This field is required.Please select all that apply.

Depression;

Anxiety;

Substance Abuse;

Other;

No Mental Illness History or Prefer Not to Say;

Are you followed by a mental health professional?* This field is required.

Yes

If yes, please specify.

Psychologist;

Psychiatrist;

Therapist/Counselor;

Other;

Emergency Contact Name* This field is required.

First Name

Last Name

Emergency Contact Relationship* This field is required.

Emergency Contact Phone Number* This field is required.

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 choose Yes or No if we have your approval to take pictures where your face may or may not be visible.

Yes

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. Please sign on the next page.

Signature* This field is required.Consent and Release

Clone of Cancer Participant Form