New Participant Form | LivingWell Cancer Resource Center

Name*

Primary Phone*

Secondary Phone

Address*

Street Address City State ZIP Code

Email Address*

Date of Birth*

Gender*

Male
Female

Name of person with cancer

Relationship

Primary Cancer Type*

Cancer Stage

Date of Diagnosis*

Date of Recurrence (if applicable)

Metastatic
Active
Remission

Primary Oncologist/Cancer Specialist

Hospital

Treatment Status

How did you hear about LivingWell? (Please select one)

Other Family Members In Household Participating In Programs:

Name

Gender

Male
Female

Date of Birth

Emergency Contact*

Emergency Contact Phone Number*

Release and Waiver:
I, the undersigned, acknowledge that I have voluntarily chosen to participate in the classes/programs/services offered by LivingWell Cancer Resource Center. I am aware that participation in some of these classes/programs/services may require physical exertion and a minimum level of physical fitness. I am voluntarily participating in the classes/programs/services and I assume all responsibility and liability for any and all injuries I may sustain due to my participation in these activities. In consideration for participation in the classes/programs/services I waive any claims or liability against LivingWell Cancer Resource Center and/or the LivingWell Cancer Resource Center staff/instructors/other participants for injury or damages that I may sustain as a result of my participation. I have read the above release and waiver of liability and fully understand its contents. I voluntarily agree to the terms and conditions stated above.

Participant Name: (please print)*

Participant Electronic Signature*

or if participant is under eighteen years old Parent/Guardian Signature*

Date*

*

I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. *

Name

This field is for validation purposes and should be left unchanged.

Participation Information Form