Member Registration
New Member
Member Information:
I am registering as a
*
Survivor/Patient
Co-Survivor/Caregiver
Today's Date
-
Month
-
Day
Year
Date
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County of Residence
*
Please Select
Allegheny
Armstrong
Beaver
Butler
Crawford
Erie
Fayette
Warren
Washington
Westmoreland
other
Phone Number
*
Format: (000) 000-0000.
E-mail
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Please Select
Cisgender Woman
Cisgender Man
Non-Binary
Transgender Woman
Transgender Man
Other
Prefer not to say
Pronouns
*
Please Select
she/her
he/him
they/them
other
Race/Ethnicity
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Please Select
American Indian/Alaskan Native
Asian/Pacific Islander
Biracial/Multiracial
Black/African American
Hispanic or Latino
Middle Eastern
White/Caucasian
Other
Prefer not to say
Marital Status
*
Please Select
Married
Domestic Partnership or Civil Union
Divorced
Separated
Widowed
Single Cohabitating with Significant Other
Single Never Married
Number of Household Members
*
Please Select
1
2
3
4
5
6+
Number of Household Members under 18
*
Please Select
none
1
2
3
4+
Annual Household Income
*
Please Select
less than $25,000
between $25,000-$49,999
between $50,000-$74,999
between $75,000-$124,999
between $125,000-$174,999
$175,000 or more
What form of cancer were you/someone you care about diagnosed with?
*
Please Select
Acute Lymphoblastic Leukemia
Acute Myeloid Leukemia
Brain Cancer
Breast Cancer
Cervical Cancer
Chronic Lymphocytic Leukemia
Chronic Myeloid Leukemia
Colon Cancer
Colorectal Cancer
Hodgkin Lymphoma
Kidney (Renal) Cancer
Liver Cancer
Lung Cancer
Lymphoma
Melanoma
Multiple Myeloma
Myelodysplastic Syndromes (MDS)
Neuroendocrine Cancer
Non-Hodgkin Lymphoma
Ovarian Cancer
Pancreatic Cancer
Prostate Cancer
Sarcoma
Testicular Cancer
Thymoma Cancer
Thyroid Cancer
Uterine Cancer
Other
If other, please provide details
Date of Diagnosis
*
-
Month
-
Day
Year
Date
Age at Diagnosis
*
What is the hospital affiliation?
*
Please Select
AHN
City of Hope
Cleveland Clinic
Dana-Farber Cancer Institute
Fox Chase Cancer Center
Fred Hutchinson Cancer Center
Johns Hopkins
Kaiser
Mayo Clinic
MD Anderson
Memorial Sloan Kettering
Mount Sinai
O'Neil Comprehensive Cancer Center
St. Clair Hospital
The James at Ohio State University
UCLA
UCSF
UPMC
Other
If you are registering as a Co-Survivor/Caregiver, what is the name of the Survivor you support
If you are registering as a Co-Survivor/Caregiver, what is your relationship to the Survivor you support
If other, please specify
Diagnosis Confirmation Documentation
Browse Files
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Choose a file
If you a survivor, please upload documentation from your provider that includes your name, date of birth, diagnosis, and date of diagnosis.
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How did you hear about us?
*
Please Select
web
word of mouth
Facebook
Instagram
Twitter
Medical Facility
UPMC Hillman Cancer Center - Distribution Day Bag
AHN - Distribution Day Bag
St. Clair - Distribution Day Bag
Other
If other, please specify
Please verify that you are human
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