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CSC New Member Form
Please fill out the form below with your contact information and a member of our staff will be in touch shortly.
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* Indicates required question
First Name
*
Your answer
Last Name
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
What is your connection to cancer?
*
Choose
I have been diagnosed with cancer
I have a loved one who has been diagnosed with cancer
Other
Virtual Programs Confidentiality and Safety
https://www.cancersupportannarbor.org/virtualpolicy/
I agree to CSC's confidentiality and safety policy.
*
Yes
Required
Date of Birth
MM
/
DD
/
YYYY
Do you have children under 18 in the home?
Yes
No
Clear selection
If yes, name (s) & age (s)
Your answer
How did you hear about the CSC? (select all that apply)
Doctor
Nurse
Social Worker or Therapist
Other Health Care Professional
Family/Friend
CSC Staff/Volunteer
Calendar/Brochure
TV/Radio
Other:
I am (check all that apply)
A person with cancer/survivor
A support person
Healthcare professional
Bereaved
Child of a loved one with cancer
Other:
Type of cancer that you or your loved one has/had:
Your answer
Treatment center where you/your loved one receive(d) care
Choose
Michigan Medicine CS Mott Children's Hospital
Michigan Medicine Rogel Cancer Center
St. Joes Ann Arbor
St. Joes Brighton
St. Joes Canton
St. Joes Chelsea
VA Medical Center
St. Mary's Livonia
Other
Marital Status
Single
Coupled
Domestic Partnership
Married
Divorced
Widowed
Clear selection
Gender Identity (check all that apply)
Man
Woman
Trans
Nonbinary
Other:
Sexual Orientation
Bisexual
Gay
Lesbian
Straight
Unknown
Other:
Clear selection
Race (check all that apply)
American Indian/Alaska Native/First Nations
Asian
Black
Native
Hawaiian/Pacific Islander
White
Other:
Ethnicity
Hispanic/Latino
Not Hispanic/Latino
Clear selection
Insurance
Medicaid
Medicare
Medicare + Private
Private
Uninsured
Clear selection
Employment Status
Employed full--time
Employed part-time
On medical leave
Disabled
Not employed
Retired
Clear selection
Annual Household Income
Under $25,000
$25,000-49,999
$50,000-74,999
$75,000-99,999
$100,000+
Clear selection
Emergency Contact Name
Your answer
Emergency Contact Relationship
Your answer
Emergency Contact Phone Number
Your answer
Submit
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