Information Form

Information Form

First Name*:

Last Name*:

Date of Birth*:

Sex*:
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Email*:

Phone number*:

Address:

City*:

State*:

Zip*:

May we send you the monthly program calendar by email?*
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Language (If not English, please specify):

How did you hear about Cancer Pathways?*

Emergency Contact*:

Emergency Phone*:

Emergency Contact Relationship*:

Family Members:

Will anyone else in your family be participating in our programs? Please list here:

Please mark which programs you are interested in
Living with Cancer Support Group
Caregiver Support Group
Bereavement Group
Mindfulness-based Art
Mindful Moments
Camp Sparkle
Kids Support Groups
Parent Support Groups

Privacy Policy
Cancer Pathways collects the above personal information for the purpose of support group registration. This information will be kept confidential and will not be shared or sold to any outside organizations, groups or individuals. By completing this form, you consent to the collection of this information by Cancer Pathways. You may request to review this information or have it deleted at any time.

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