CSCP New Member Form

All programs and services are offered at no charge to cancer patients and their loved ones. This is made possible by the generous donations of our participants, other individuals, and grants. We are not affiliated with any insurance company and we do not receive Federal or State funding. Please complete all parts of this form. The information helps us know who we serve, track needs, and understand how people are referred to us. As a nonprofit organization, information about who we serve (in statistical form only, never about an individual) is critical to ensuring continued funding. Thank you!

Today's Date:

Preferred Title:

Mr. Mrs. Miss Ms.

Name: *

First Name Last Name

Street Address:

City: *

State: *

Zip Code: *

Are you currently residing in California? *

Yes No

Email:

example@example.com

Would you like to receive our weekly program line-up by email?

Yes No

Phone (Home):

Phone (Mobile):

Date of Birth:

Age:

I identify as:

Male Female Transgender Non-Binary Prefer to Not Answer

Marital Status:

Single Married Partnered Seperated Divorced Widowed

Do you have any children between the ages of 5 and 18?

Yes No

If yes, what age(s)?

I am a: *

Cancer Patient or Survivor Caregiver/Loved one Experienced the recent death of a cancer patient

Type of Cancer:

Date of Diagnosis:

Doctor/Oncologist:

Hospital:

Loved One's Name:

Loved One's Cancer:

Date of Passing:

Cancer Patient's Name:

Cancer Patient's Diagnosis:

How did you learn about Cancer Support Community Pasadena? (check all that apply) *

Specific Referral Source:

Several of our funding and accrediting agencies require us to ask for the following demographic information. The following information will be used for statistical purposes only and is not linked to your name.

Ethnic Background:

White (not Hispanic) Latino/Hispanic American Indian Asian/Pacific Islander African American/Black (Non-Hispanic) African American/Black (Hispanic)

Number in Household:

Annual Family Income:

Under $25,000 $25,000-$49,999 $50,000-$74,999 $75,000-$99,000 Over $100,000

Insurance Status:

Medicare Medi-Cal/Medicaid Private Insurance Uninsured

Employment Status:

Full Time: Part Time On Medical Leave Disabled Not Employed Retired

Please select which technology you have access to: (check all that apply)

Wi-fi Cell Phone Tablet Laptop Desktop

Emergency Contact:

Relationship:

Emergency Contact Phone:

Area Code Phone Number

This portion of the document indicates your consent to participate in distance-oriented classes, which take place over a telehealth platform, Zoom.

Our staff and volunteers respect the privacy of our members. Cancer Support Community Pasadena (CSCP) adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law. I fully understand that CSCP and program partners recommend that anyone participating in any exercise program check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any exercise program could result in injury or illness.

CSCP asks that our members respect each other’s privacy and do not disclose the identity of others who participate at CSCP, or what is said in a support group or program. However, we are not able to ensure confidentiality of all members, as we would have no way to enforce it. Please read, initial, and sign below regarding our policies for the confidentiality, comfort and safety of our members.

By signing this document, I agree to release, waive, discharge and hold harmless CSCP and its program partners, affiliates, employees, officers, agents, independent contractors, volunteers and donors from any and all claims, actions, demands, liabilities, expenses (including attorneys’ fees) and losses arising from bodily injury or illness, including, but not limited to, wrongful death, loss of services, loss of consortium, and all other damages that may arise out of participation in the exercise program.

By signing this consent, I hereby indicate my compliance with the above stated telehealth platform Zoom experience and reserve the right to revoke my consent, inwriting, at any time. Please print, date, and sign your name below indicating that you have read and understand the contents of this form, you agree to these policies, and you are authorizing your clinician to utilize the online platform, Zoom method above.

Signature *

Clear