Canc3rPress Pre-Qualification Form
Share your background and goals so Canc3rPress can assess fit and readiness for next steps—this is not a substitute for medical care or emergency services.
Contact Information
Full Name
*
First Name
Last Name
Preferred Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone
Text Message
Either
City
*
State
*
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Other
Age Range
Please Select
Under 18
18–24
25–34
35–44
45–54
55–64
65–74
75+
Prefer not to say
Cancer Survivor Path
Cancer type or diagnosis
*
Please Select
Breast cancer
Prostate cancer
Lung cancer
Colorectal cancer
Lymphoma
Leukemia
Melanoma
Gynecologic cancer
Head and neck cancer
Other cancer type
Prefer not to answer
Current stage in your cancer journey
*
Newly diagnosed
Active treatment
Post-treatment / recovery
Long-term survivorship
Recurrence / metastatic disease
Other
Prefer not to answer
Approximate date of diagnosis
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Current treatment status
*
Please Select
Not currently in treatment
Receiving treatment now
Completed treatment
Treatment paused
Other
Prefer not to answer
Has your healthcare team placed any restrictions on physical activity or wellness participation?
*
Yes
No
Unsure
Prefer not to answer
If required, is medical clearance available?
Yes
No
Not sure
Not applicable
Prefer not to answer
Primary goals
Strength
Mobility
Endurance
Fatigue management
Stress reduction
Spiritual wellness
Community / support
Healthy lifestyle
Other
Current activity level
*
Sedentary
Lightly active
Moderately active
Very active
Varies by treatment phase
Unsure
Prefer not to answer
Accessibility or accommodation needs
Chair-based options
Low-impact options
Rest breaks
Mobility support
Virtual participation
Large-print materials
Quiet environment
Captioning / hearing support
Other
What support are you hoping to receive from Canc3rPress?
Anything else we should know about your cancer survivorship journey
Caregiver Path
Relationship to the person with cancer
*
Please Select
Spouse/Partner
Parent
Child
Sibling
Other Family Member
Friend
Neighbor
Other
Current caregiving status
*
Active caregiver
Former caregiver
Bereaved caregiver
Other
Approximate length of caregiving experience (years)
Primary caregiver challenges and needs
Stress
Fatigue
Physical wellness
Emotional support
Spiritual wellness
Community
Education/resources
Other
What wellness goals would you like to work toward?
Current activity level
Low
1
2
3
4
5
6
7
8
9
High
10
1 is Low, 10 is High
Accessibility or accommodation needs
What support do you hope to receive from Canc3rPress?
Oncology Clinician/Healthcare Professional Path
Professional Title / Role
*
Organization / Practice Name
*
Specialty
*
Years Working in Oncology
*
Professional Credentials / Licensure
What interests you about Canc3rPress?
*
Referring patients/survivors
Caregiver support
Collaboration/partnership
Professional education
Program participation
Community outreach
Other
Populations Served
What would you hope to gain from or contribute to Canc3rPress?
Preferred Method for Future Professional Communication
*
Please Select
Email
Phone
Text message
Virtual meeting
Other
Spiritual Wellness
Is spiritual or faith-based support important to your wellness journey?
*
Yes
Somewhat
No
Prefer not to answer
Are you comfortable with Canc3rPress incorporating Christian faith-based encouragement and resources?
*
Yes
No
Prefer not to answer
Optional: Share any spiritual needs, prayer requests, or faith-related goals
Readiness and Safety
Are you ready to participate in a wellness program at this time?
*
Yes
No
Not sure
Please share any physical limitations, accommodations, or support needs we should know about
Are there any circumstances that require individualized professional guidance before participating?
*
No
Yes
Not sure
Program Interest
Which Canc3rPress offerings are you interested in?
*
Fitness/Wellness
Survivorship Support
Caregiver Wellness
Spiritual Wellness/Christian Encouragement
Educational Resources
Community Events/Support
Clinician Collaboration/Referrals
Other
Preferred participation format
*
In-person
Virtual
Hybrid
No preference
Scheduling preferences
How did you hear about Canc3rPress?
Please Select
Healthcare professional
Church or faith community
Social media
Website search
Friend or family
Community event
Printed flyer
Other
Consent and Acknowledgment
I confirm the information provided is accurate to the best of my knowledge
*
I confirm
I understand that Canc3rPress wellness programming does not replace medical diagnosis, treatment, or emergency care
*
I understand
I consent to be contacted about eligibility, next steps, and relevant Canc3rPress services
*
I consent
I would like to receive general program and news updates from Canc3rPress
Yes
Submit
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