Connect Thru Cancer Client Registration Form 2023-24
If you have any questions please contact us by email at info@connectthrucancer.org.  Please note: This organization provides programs of support to cancer patients and their families. Unfortunately, we do not provide direct financial assistance, but we do provide support engagement programs and events free of charge.
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Client Name *
Client Email *
Cell Phone *
Address  Street Name  *needed for shipping books, when applicable, verify in-home support available and to track geographical reach of our programs. *
City *
State
Zip *
Emergency Contact/Spouse *
Cancer Diagnosis *
Stage
Treatment (check all that apply) *
Required
Are you currently in treatment? *
If no what is the date of your last treatment?
What Hospital/ Cancer Center are you receiving treatment? *
What is the name of your Nurse Navigator and Social Worker? (We like to let them know when we are supporting their patients)
What is the name of your Oncologist?
Client Age *
Number of Children: Name, Gender, Age (Helps with resources appropriate for them) *
I am interested in learning about your in-home program (Offered weekly for 1.5 hours/week to provide creative play with young kids at home and respite to the parent) *Currently offered to the Tri-County Philadelphia Area: Chester, Delaware and Montgomery County *
For In Home Program:  # of Children, Name(s)  | Age(s) | Special Concerns *
Household Income: *
Ethnicity *
Would you like a phone call to learn more about our in-person programs? Specifically our in-home support programs and monthly family fun days? *
Please tell about what type of support you need most. If we do not provide that we can try to send you resources that may help. *
Out of State Residents: At this time we are offering specific workbooks for cancer patients, teens and kids that can be mailed to you. We can also send a list of additional resources available to help you navigate the treatment process.
How did you hear about our programs?
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