Participation Registration Page Please complete all fields to help us better serve you Name*DOB* Date Format: MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Primary Phone*Secondary PhoneEmail* Gender*MaleFemaleOtherOther*Occupation*Employer*Check which best describes you (select all that apply)* Diagnosed with Cancer Caregiver Seeking Grief Support Other Other*Type of diagnosis*My (select below) has been diagnosed with cancerSpouse/PartnerParentChildSiblingFriendNameType of DiagnosisI am interested in programs and services to the following (select all that apply)* Support Groups Individual Counseling Wigs & Beauty Nutrition & Meal Preparation Food Pantry Caregiver Support & Strategies Financial or Legal Counseling Physical Activity and Exercise Massage & Reiki Family & Youth Programs Communicating with my Loved ones Long-Term Survivorship Other OtherIf you are or have been treated for cancer, which type of treatment are/were you receiving? (Select all which apply) Surgery Chemotherapy Radiation Hormone Therapy Reconstructive Surgery Name of Oncologist or Physician First Which medical facility/provider are you or your loved one receiving care?*How did you hear about Stewart's Caring Place?All programs and services at Stewart's Caring Place are provided at no-cost, regardless of income. Some organizations who provide funding to our agency require us to collect statistical information in order to receive funding. Thank you for completing the optional below. Your individual information will never be released.Please Indicate which best describes your current health care coverage (select all that apply) Private Insurance Medicare Medicaid No health care coverage Applying for coverage Ethnicity (select one)African AmericanAfrican BornArab AmericanAsianCaucasianHispanicMiddle EasternNative AmericanOtherOtherAnnual Household Income (select one)Less than $5,000$5,000-$9,999$10,000-$14,999$15,000-$19,999$20,000-$29,999$30,000-$39,999$40,000-$49,999$50,000-$59,999$60,000-$69,999$70,000-$79,999$80,000-$99,999$100,000+UnknownSource(s) of incomeTotal number of individuals living in the householdNumber of minors living in the householdI understand and agree that my consent to these services is given in consideration of my being permitted to participate in the complementary or alternative health care services provided by Stewart's Caring Place. I acknowledge that I am a voluntary participant in these activities and assume full and complete responsibility for any injury, loss, or damage which may occur during my participation in these events while on the premises of Stewart's Caring Place. I hereby release and hold harmless Stewart's Caring Place, the complementary or alternative health care provider, and all employees, agents, and directors of Stewart's Caring Place for any and all claims, causes of action, suits or other proceedings which in any way relate to my participation in the complementary or alternative health care services upon the premises of Stewart's Caring Place for personal injuries or any other damages sustained. I have received a copy of the policies of Stewart's Caring Place and acknowledge my understanding of them.Signature*Date of Signature*Emergency ContactEmergency Contact Phone*Emergency Contact Relationship*Emergency Contact Name*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.