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Contact Information
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AFGHANISTAN
ALAND ISLANDS
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ANDORRA
ANGOLA
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ANTARCTICA
ANTIGUA AND BARBUDA
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* I understand that by providing a cell phone number I agree to receive text messages as part of my volunteering activities.
My Information
My Gender
Gender
Female
Male
Other
Prefer not to answer
I am a...
Cancer Survivor
Family member / caregiver
Both
Cancer Type. If your cancer type is not listed, choose Other.
Select ...
Adenocarcinoma
Anus
Appendix
Appendix - Adenocarcinoma
Bile duct (Liver)
Bladder
Blood
Blood - ALL
Blood - AML
Blood - APL
Blood - CLL
Blood - CML
Bone
Bone - Osteosarcoma
Brain
Breast
Breast - Adenocystic Carcinoid
Breast - BRCA+
Breast - DCIS
Breast - Ductal
Breast - Estrogen and/or Progesterone Positive
Breast - HER 2+
Breast - In Situ
Breast - Inflammatory
Breast - Invasive
Breast - Lobular
Breast - Paget Disease
Breast - Triple Negative
Breast - Triple Positive
Burkitts Lymphoma
Cervix
Colon
Diffuse Large B-Cell Lymphoma
Duodenum
Duodenum - Adenocarcinoma
Endometrium
Esophagus
Ewing Sarcoma
Eye
Follicular Lymphoma
Head & Neck
Hodgkin's Lymphoma
Kidney
Larynx
Liver
Lung
Lung - Adenocarcinoma
Lung - Small Cell & Non Small-Cell Carcinoma
Lymphoma - Large B-Cell
Lymphoma - Primary Mediastinal
Mantle Cell Lymphoma
Melanoma
Melanoma - Eye
Mesothelioma
Multiple Myeloma
Neuroendocrine Tumor
Non-Hodgkin's Lymphoma'
Other
Ovary
Ovary - Adenocarcinoma
Pancreas
Papillary Thyroid
Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma)
Prostate
Rectum
Sarcoma
Skin
Spindle Cell Sarcoma
Squamous Cell Carcinoma
Stomach
Testicle
Throat
Thymoma
Thyroid
Tongue
Uterus
Describe other cancer type
Date of diagnosis. Approximate date is acceptable.
Stage of Cancer
Select ...
Unsure
N/A
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Cancer Treatment. Select all that apply. If your treatment is not listed, choose Other.
BMT / SCT
Chemotherapy
Hormone Therapy
Hospice (no longer seeking treatment)
Immunotherapy
Lobectomy
Ostomy
Other
Palliative Care
Radiation
Surgery
Surgery - double mastectomy
Surgery - lumpectomy
Surgery - reconstruction
Surgery - resection
Surgery - single mastectomy
Surgery - thyroidectomy
To be determined
Describe other treatment
Are you or your loved one still receiving treatment?
Select ...
No
Yes
I am comfortable discussing the following (choose all that apply):
Feelings related to my or my loved one’s diagnosis and treatment
How to cope and make it through this.
How treatment is affecting me or my loved one
Questions or concerns I have about my loved one’s or my cancer and how to discuss those with my treatment team
The impact of cancer on me and my family
I am comfortable discussing the following (choose all that apply):
Metastasis location
Bone
Brain
It Has Not Spread
Liver
Lung
Lymph Nodes
Other
Describe other metastasis location
Tell us about the challenges you faced. For survivors: what challenges did you experience as the result of your treatment (lymphedema, loss of taste, types of complications from reconstruction, changes in independence, changes in family life, etc.)? For caregivers: what challenges did you experience as the result of caring for a loved one during his/her treatment?
Care receiver Information
The care receiver is my
Select...
Aunt/Uncle
Brother
Brother-in-law
Daugher-in-law
Daughter
Extended Family
Father
Father-in-law
Friend
Grandfather
Grandmother
Husband
Mother
Mother-in-law
Same Sex Partner
Sister
Sister-in-law
Son
Son-in-law
Wife
Other (not listed)
The care reciever is/was my...
Age of Care Receiver at Diagnosis
Select...
child
infant
teenager
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
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80
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82
83
84
85
86
87
88
89
91
92
93
94
95
96
97
98
99
The care receiver's gender is
Select...
Female
Male
Not Specified
Did your care receiver survive?
Select ...
No
Yes
Cancer Type. If your cancer type is not listed, choose Other.
Select ...
Adenocarcinoma
Anus
Appendix
Appendix - Adenocarcinoma
Bile duct (Liver)
Bladder
Blood
Blood - ALL
Blood - AML
Blood - APL
Blood - CLL
Blood - CML
Bone
Bone - Osteosarcoma
Brain
Breast
Breast - Adenocystic Carcinoid
Breast - BRCA+
Breast - DCIS
Breast - Ductal
Breast - Estrogen and/or Progesterone Positive
Breast - HER 2+
Breast - In Situ
Breast - Inflammatory
Breast - Invasive
Breast - Lobular
Breast - Paget Disease
Breast - Triple Negative
Breast - Triple Positive
Burkitts Lymphoma
Cervix
Colon
Diffuse Large B-Cell Lymphoma
Duodenum
Duodenum - Adenocarcinoma
Endometrium
Esophagus
Ewing Sarcoma
Eye
Follicular Lymphoma
Head & Neck
Hodgkin's Lymphoma
Kidney
Larynx
Liver
Lung
Lung - Adenocarcinoma
Lung - Small Cell & Non Small-Cell Carcinoma
Lymphoma - Large B-Cell
Lymphoma - Primary Mediastinal
Mantle Cell Lymphoma
Melanoma
Melanoma - Eye
Mesothelioma
Multiple Myeloma
Neuroendocrine Tumor
Non-Hodgkin's Lymphoma'
Other
Ovary
Ovary - Adenocarcinoma
Pancreas
Papillary Thyroid
Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma)
Prostate
Rectum
Sarcoma
Skin
Spindle Cell Sarcoma
Squamous Cell Carcinoma
Stomach
Testicle
Throat
Thymoma
Thyroid
Tongue
Uterus
Describe other cancer type
Date of diagnosis. Approximate date is acceptable.
Stage of Cancer
Select ...
Unsure
N/A
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Cancer Treatment. Select all that apply. If your treatment is not listed, choose Other.
BMT / SCT
Chemotherapy
Hormone Therapy
Hospice (no longer seeking treatment)
Immunotherapy
Lobectomy
Ostomy
Other
Palliative Care
Radiation
Surgery
Surgery - double mastectomy
Surgery - lumpectomy
Surgery - reconstruction
Surgery - resection
Surgery - single mastectomy
Surgery - thyroidectomy
To be determined
Describe other treatment
Are you or your loved one still receiving treatment?
Select ...
No
Yes
Metastasis location
Bone
Brain
It Has Not Spread
Liver
Lung
Lymph Nodes
Other
Describe other metastasis location
Other Information
If you prefer in-person training, please select the appropriate city.
Select...
Atlanta
National/Houston
Have you ever been matched with a CanCare volunteer?
Select ...
No
Yes
How did you hear about this volunteer opportunity?
Select ...
Memorial Hermann
Doctor or Healthcare Provider
Facebook
Friend or Family Member
Internet Search
My CanCare Volunteer or CanCare Staff
News Report/ Radio/ TV
Place of Employment
Place of Worship
Volunteer Match
Other
Describe other referral
Marital Status
Select ...
Single
Married
Partner
Same Sex Relationship
Widowed
Divorced
Separated
Spouse/partner First Name
Spouse/partner Last Name
Languages in which you are fluent
Afrikaans
Albanian
American Sign Language
Amharic
Arabic
Armenian
Bangka
Bengali
Bosnian
Burmese
Cambodian
Cantonese
Chinese
Creole
Crijarati
Croatian
Czech
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Dutch
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Fujinese
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German
Greek
Gujarati
Hakka
Hebrew
Hindi
Hungarian
Italian
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Malaysian
Mandarin
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Nigerian
Norwegian
Pakistan
Pashto
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian
Shanghainese
Sinhalese
Slovak
Spanish
Swahili
Swedish
Tagalog
Taiwanese
Telugu
Thai
Turkish
Ukrainian
Ulithian
Urdu
Vietnamese
Yiddish
Yoruba
Zulu
Please list all the years your children were born
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
What is the quickest way to reach you during business hours?
Select ...
Email
Phone
Text
If you or your loved one had a recurrence, what stage was the recurrence?
Select ...
Unsure
N/A
Stage 0
Stage 1
Stage 2
Stage 3
Stage 4
Primary Cancer Physician
With which hospital is this doctor affiliated?
Where did you or your care receiver have treatment?
Are you interested in offering support in-person at hospitals/treatment centers (Houston and Atlanta areas only)?
Select ...
Yes
No
Maybe
Place of employment
Occupation
At the time of diagnosis, what was your employment status?
Do you have experience in the following areas? If so, please select the areas you are interested in volunteering your skills
Accounting
Adult Education
Advertising
Advocacy
Architect
Attorney
Bookkeeping
Budgeting
Carpentry
Catalyst
Catering/Special Events
Certified Health Professional
Certified HR Professional
Chairing Meetings
Coalition Building
College Education
Communicating in Writing
Computer Maintenance/Programming
Computer Networking
Computers/Information Technology
Conference Workshop Planner
Contacting Businesses/Foundations
Contacting Media
Cooking
Cooking Prep
Counseling Training
Data Entry
Data Security
Database Administration
Decorations
DeleMilitarygating
Dentist
Desktop Publishing/Graphic Design
Developing Audio visuals
Developing Ideas
Developing/Interpreting Bylaws
Dietician
Dispatch
Donor programs
Drafting Legislation
Driving Car/Light truck
Education Administration
Elected Official
Elementary Education
Endowment funds
Engineering
Facilitating
Fashion/Costume Design
Filling/Sorting
Film/Video Tape Production
Financial Plans/Forecasting
Floral Design
Food Service
Gourmet Food Preparation
Governance
Greeter
High School Education
Historian/Archives/Scrapbook
Hospital Administration
Hotel Management
Human Resources
Influencing Public
Inspector
Instruction/Facilitation
Interior Design
Interpreter(Spoken)
Interviewing
Inventory
Investing/Finance
Journalism
Judge
Kitchen Management
Law Enforcement
Lawyer
Layout
Licensed Amateur Radio Operation
Licensed Child Care Worker
Licensed Medical Professional
Licensed Mental Health professional
Licensed Teacher
Lobbying
Mail Distribution
Marketing Plans
Media Relations
Media Specialist
Microsoft Excel
Microsoft Power Point
Microsoft Word
Middle School Education
Military
Motivating
MSW Degree
Musical (Instrument) Skills
Musical (Voice) Skills
Nurse
Optometry
Organizing
Painting
Parliamentary Law
Party Planning
Personal Management
Pharmacist
Photography
Physician
Planning
Planning Events
Political Science Degree
Postage/Lettering/Signage
Preschool Education
Problem Solving
Program Evaluation
Project Development/Research
Psychology
Public Relations
Public Speaking/Training
Puppetry
Purchasing
Quick Books
Realtor
Recreation / Games
Report Writing
Research
Risk Management
Safety and/or Security
Sewing
Social Media
Special Education
Stage/Set Design
Strategic Planning
Supervision
Survey/Polls
System Administration
Technical Writing
Theatrics
Training
Translator (Written)
Transportation
TV Broadcasting Experience
Valid Commercial Driver’s License
Volunteer Relations
Warehouse
Website Development
Writing Copy/Editing
Writing Grants
Writing Proposals
Religious Affiliation and/or Place of Worship
Reason for volunteering
Emergency Contact
First Name
Last Name
Phone Number
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