Kick It Cancer Screening Pledge

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This form is for follow up purposes only

Name (First, Last) *

Best contact number (optional)

Email address *

Please provide the city/community where you currently reside *

Please select your age group *

18-25

26-40

41-65

65+

Please select one

I am a cancer survivor

I am not a cancer survivor

Clear selection

Please select your pledge *

I pledge to get screened for breast cancer within 6 months

I pledge to get screened for prostate cancer within 6 months

I pledge to get screened for cervical/HPV cancer within 6 months

I pledge to get screened for colon cancer within 6 months

I pledge to get screened for lung cancer within 6 months

I pledge to get screened for skin cancer within 6 months

I pledge to get screened for bladder cancer within 6 months

Other:

Required

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