New Participant Form | LivingWell Cancer Resource Center

Name*

Address*

Street Address City State ZIP Code

Email Address*

Date of Birth*

Gender*

Male
Female

Primary Phone*

Primary Phone Type

Secondary Phone

Secondary Phone Type

Emergency Contact*

Emergency Contact Phone Number*

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

Pre-treatment
Active treatment
Completed treatment during past 18 months
Treatment completed more than 18 months ago

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

LivingWell Program Guide in cancer centers or hospitals
E-mail
Facebook (facebook.com/livingwellcrc)
LivingWell website (www.livingwellcrc.org)
Fliers at cancer centers or hospitals
My Physician
Social Worker
Friend or family member

Other Family Members In Household Participating In Programs:

Name

Gender

Male
Female

Date of Birth

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. *

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Participation Information Form