Erie Cancer Wellness Center
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Participant Registration Form

"*" indicates required fields

Welcome to the Erie Cancer Wellness Center!

We are glad you've found us. Please take a few moments to share a little about yourself and your cancer experience. Once you have completed this information, you are a member and are invited to begin coming to the activities that interest you.
Name*
Address*
D.O.B.*
How would you prefer to be contacted after signing up for classes/programs?*

Your Cancer Experience

Date of PRIMARY Diagnosis*
Have you been diagnosed with Metastatic/Stage 4 cancer?*
Are you currently receiving treatment?*
What is/was the treatment plan?

Your Support System & Emotional Health

Do you have a history of any of the following? (Please check all that apply)
Are you followed by a mental health professional?

As things stand today, are you interested in support that focuses on...

Increasing the support/help in my life
Coping with worry/fear
Regaining sense of control
Helping to manage the frequency/intensity of sadness/crying spells
Not feeling so overwhelmed
Concerns about my children and/or grandchildren
Connecting with others/decreasing feelings of isolation
Are you interested in short-term individual sessions?*

Family & Youth Support

Do you have children/grandchildren under the age of 18 who are interested in support?*

Helpful Info

How did you hear about the Erie Cancer Wellness Center? Please check all that apply*

Please list additional members of your family, under the age of 18 who will be coming to the Erie Cancer Wellness Center

Name
D.O.B.
Name
D.O.B.
Name
D.O.B.
Name
D.O.B.

Cool gradient pattern image by Erie Cancer Wellness Center

Supporting Wellness

As a 501(c)(3) nonprofit organization, The Erie Cancer Wellness Center relies on our friends, donors, partners, and community supporters. The organization is 100% privately funded, not receiving government monies or insurance reimbursement. Funding for The Erie Cancer Wellness Center is provided by tax-deductible donations from a caring community of individuals, families, foundations, and businesses.

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