July 15, 2016

Information Form

Information Form

Your Name*:

I am a*: Person With CancerFamily Member/FriendVolunteerOther

Address*:

City*:

State*:

Zip*:

Phone 1*:

Land Line:

May we leave you phone messages?*
YesNo

Date of Birth*:

Sex*:
MFOther

Your Email*:

May we send you the monthly program calendar by email?*
YesNo

Occupation/Interests*:

Language (If not English, please specify):

How did you hear about Cancer Pathways?*

What is your medical diagnosis or the diagnosis of the person in your life who has/had cancer?*

Emergency Contact*:

Emergency Phone*:

Emergency Contact Relationship*:

Physician*:

Physician Phone*:

Hospital/Treatment Center*:

Family Members:

Spouse/Partner:

Do you have children under 18?*
YesNo

Please list your children here, Full Name, Sex, Age, and Date of Birth:

Cancer Pathways gathers information about every Participant to help us better understand who comes to our programs. All personal information will be kept confidential. Since we are a non-profit organization that does not charge for our services, we rely solely on donations to underwrite our programs. The following information would better help us to secure funding. The information provided to funders will only be in terms of combined demographic data of all Participants with no identifying information. Your answers to these questions will, in no way, affect your ability to access all programs at Cancer Pathways or other off-site locations at no charge.

Race/Ethnicity:

White (non-Hispanic)Black/African American (non-Hispanic)White-HispanicBlack-HispanicAmerican Indian/Alaska Native/First NationsAsian/Pacific IslanderOther

Insurance:

Medicare onlyMedicare + PrivateMedicaidPrivate InsuranceUninsured

Employment Status:
Employed full-time or part-timeOn medical leaveDisabledNot EmployedRetired

Are you interested in joining a support group?

For adults:
Living with Cancer Group for adults with any cancer diagnosis (Seattle, Federal Way, Bellevue)Caregiver Group (Seattle, Federal Way, Woodinville)Bereavement Group (Bellevue)

For Families:
Camp Sparkle 2017 for kids ages 5-12Family Support Groups (Art therapy for children 6-12 and networking for parents)Family fun eventsTeen Retreat (for teens ages 13-18)

Today's Date:

Signature

*Required