Cancer Support Interest Form
Please complete this form if you are interested in Cancer Support at Gilda's Club Grand Rapids or our Lowell Clubhouse. A member of our program staff will contact you with more information. If you have any questions please call us at 616-453-8300 or email us at
register@gildasclubgr.org
.
You may
click here
to download a form to mail in or fill out the form below.
Name
*
First
Last
Suffix
Date of Birth
*
Address
*
Street Address
Address Line 2
City
State
Postal / Zip Code
County
Male or Female?
Male
Female
Please email me the calendar monthly
Yes
No
Email
*
Phone Number
*
(###-###-####)
work phone - optional
Employer (if any)
Occupation
How did you hear about Gilda's Club?
Do you wish to receive information about donating to Gilda's Club, fundraising events and activities?
Yes
No
Cancer Connection
I was diagnosed:
Type:
My loved one was diagnosed:
Type:
Name and Relationship
Date of Diagnosis
(##-##-####)
Your Medical Information - ONLY if you are diagnosed.
Primary Physician
Oncologist
Hospital
Emergency Contact Information
Emergency Contact Name
Relationship
Phone Number
*required
Do Not Fill This Out
