If you are seeking support for someone else, DO NOT COMPLETE THIS FORM. Please email - support@cancare.org so that we ensure that your loved ones needs are met. 

If you need Resources - Financial, Housing, Home Health, Transportation, Medical Expenses click here.

To personalize your match with a CanCare volunteer for emotional support, please complete the information below.

The information you provide, including your contact information and cancer history, will be used by CanCare staff and will only be provided to your dedicated volunteer so they can connect with you and support your needs.

***For assistance with this form contact our matching team at 346-421-5777.

 

Profile Information

First Name

Last Name

Email

Date of Birth

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Contact Information

Country Select ... AFGHANISTAN ALAND ISLANDS ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA, PLURINATIONAL STATE OF BONAIRE, SINT EUSTATIUS AND SABA BOSNIA AND HERZEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORY BRUNEI DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO, THE DEMOCRATIC REPUBLIC OF THE COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CURA CYPRUS CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS (MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN TERRITORIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND AND MCDONALD ISLANDS HOLY SEE (VATICAN CITY STATE) HONDURAS HONG KONG HUNGARY ICELAND INDIA INDONESIA IRAN, ISLAMIC REPUBLIC OF IRAQ IRELAND ISLE OF MAN ISRAEL ITALY JAMAICA JAPAN JERSEY JORDAN KAZAKHSTAN KENYA KIRIBATI KOREA, DEMOCRATIC PEOPLE'S REPUBLIC OF KOREA, REPUBLIC OF KUWAIT KYRGYZSTAN LAO PEOPLE'S DEMOCRATIC REPUBLIC LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAO MACEDONIA, THE FORMER YUGOSLAV REPUBLIC OF MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA, FEDERATED STATES OF MOLDOVA, REPUBLIC OF MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PALESTINIAN TERRITORY, OCCUPIED PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIAN FEDERATION RWANDA SAINT BARTH SAINT HELENA, ASCENSION AND TRISTAN DA CUNHA SAINT KITTS AND NEVIS SAINT LUCIA SAINT MARTIN (FRENCH PART) SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SINT MAARTEN (DUTCH PART) SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA AND THE SOUTH SANDWICH ISLANDS SOUTH SUDAN SPAIN SRI LANKA SUDAN SURINAME SVALBARD AND JAN MAYEN SWAZILAND SWEDEN SWITZERLAND SYRIAN ARAB REPUBLIC TAIWAN, PROVINCE OF CHINA TAJIKISTAN TANZANIA, UNITED REPUBLIC OF THAILAND TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNITED STATES MINOR OUTLYING ISLANDS URUGUAY UZBEKISTAN VANUATU VENEZUELA, BOLIVARIAN REPUBLIC OF VIET NAM VIRGIN ISLANDS, BRITISH VIRGIN ISLANDS, U.S. WALLIS AND FUTUNA WESTERN SAHARA YEMEN ZAMBIA ZIMBABWE

State Select ... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Postal Code

Address

Address 2

Address 3

Address 4

Address 5

Phone Number

Other Information

I am a...

Patient

Family member / caregiver

The Patient 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)

Other Patient Relationship

Are you open to receiving support from a volunteer whose loved one did not survive? Select ... No Yes

My Gender Gender Female Male Other Prefer not to answer

CANCER TYPE Select ... Adenocarcinoma Anus Appendix Appendix - Adenocarcinoma Bile duct (Liver) Bladder Blood 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 Cervix Colon Duodenum Duodenum - Adenocarcinoma Endometrium Esophagus Ewing Sarcoma Eye Head & Neck Kidney Larynx Leukemia - ALL Leukemia - AML Leukemia - APL Leukemia - CLL Leukemia - CML Liver Lung Lung - Adenocarcinoma Lung - Small Cell & Non Small-Cell Carcinoma Lymphoma - Burkitt Lymphoma - Diffuse Large B-Cell Lymphoma - Follicular Lymphoma - Hodgkin's Lymphoma - Large B-Cell Lymphoma - Mantle Cell Lymphoma - non-Hodgkin's Lymphoma - Primary Mediastinal Melanoma Melanoma - Eye Mesothelioma Multiple Myeloma Neuroendocrine Tumor Other Ovary Ovary - Adenocarcinoma Pancreas Papillary Thyroid Pleomorphic Sarcoma (Malignant Fibrous Histiocytoma) Prostate Rectum Salivary gland Sarcoma Skin Spindle Cell Sarcoma Squamous Cell Carcinoma Stomach Testicle Throat Thymoma Thyroid Tongue Uterus

Describe other cancer type

Stage of Cancer? Select ... Unsure N/A Stage 0 Stage 1 Stage 2 Stage 3 Stage 4

Treatment, please select all that apply. Provide details below. Clinical Trials Watch and Wait 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

Describe other metastasis location

Cancer survivors, if we do not have someone with the same type of cancer available, are you open to a match with someone who has a different cancer type? Caregivers are matched based on your relationship with your care receiver. Select ... No Yes

What is the best way for your volunteer to contact you? Email Phone Text

Are you open to a volunteer of the opposite sex? Select ... No Yes

How did you hear about CanCare? 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 Other

Describe other referral

Name of doctor

Name of hospital

Please include any information that will help us make the best match for you - For example, what would you like to discuss with your volunteer, where are you in your treatment, what is the best time to reach you.