New Membership FormWe gather information about every Member to better understand who comes to our programs. Personal information will be kept confidential. As a non-profit organization that does not charge for our services, we rely solely on donations to underwrite our program and need the following information to help secure funding. Information provided to funders does not include identifying information. Your answers will, in no way, affect your ability to access all programs at Gilda’s Club Quad Cities at no charge. Please enter your email address Proceed Already have an account? Login here Personal Information First Name * Mr. Mrs. Ms. Prof. Dr. Rev. Pastor Sister Dcn. Fr. Middle Name Last Name * Suffix Preferred Name Home Address * City * Country * United States Canada Australia New Zealand ------------------------- Afghanistan Albania Algeria Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Austria Azerbaijan Azores Bahamas Bahrain Bangladesh Barbados Belarus Belgium Benin Bermuda Bhutan Bolivia Bosnia-Herzegovina Botswana Brazil British Honduras (Belize) British Virgin Islands Brunei Darussalam Bulgaria Burkina Faso Burma Burundi Cambodia Cameroon Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos Island (Australia) Colombia Comoros Congo (Brazzaville),Republic of the Congo, Democratic Republic of the Cook Islands (New Zealand) Costa Rica Cote d'Ivoire (Ivory Coast) Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor (Indonesia) Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French West Indies (Guadeloupe or Martinique) Gabon Gambia Georgia, Republic of Germany Ghana Gibraltar Great Britain and Northern Ireland Greece Greenland Grenada Guadeloupe Guatemala Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, Republic of Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte (France) Mexico Moldova Monaco (France) Montserrat Morocco Mozambique Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia Nicaragua Niger Nigeria Niue (New Zealand) Norfolk Island (Australia) North Korea Norway Oman Pakistan Panama Papua New Guinea Paraguay Persia (Iran) Peru Philippines Pitcairn Island Poland Qatar Reunion Romania Russia Rwanda Saint Helena Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia-Montenegro Seychelles Singapore Slovak Republic Slovenia Solomon Islands Somalia South Africa South Georgia (Falkland Islands) South Korea Spain Sri Lanka St. Christopher and Nevis Sudan Suriname Swaziland Sweden Switzerland Taiwan Tajikistan Tanzania Thailand Togo Tokelau (Union) Group (Western Samoa) Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Islands Western Samoa Yemen Zambia Zimbabwe State * Zip / Post Code * Email * Home Phone Business Phone Mobile Phone Date of Birth * Loading… April 2021 SunMonTueWedThuFriSat 1328293031123 1445678910 1511121314151617 1618192021222324 172526272829301 182345678 TodayClear JanFebMarApr MayJunJulAug SepOctNovDec OKCancel Gender * Other Woman Man Nonbinary Transwoman Transman N/A To choose or Change a password, Enter it twice below: New Password New Password (confirm) Choose a Photo Cancel GENERAL INFORMATION Location of Form Completion Select… Davenport Clubhouse Clinton Outreach Muscatine Outreach Online Other Employer Do you have children under 18?YesNo I am registering as a: Select… Living with Cancer Survivor Support Person Bereaved Health Care Professional If a support person, who are you here to support? If a bereaved person, when did your loved one die? Loading… April 2021 SunMonTueWedThuFriSat 1328293031123 1445678910 1511121314151617 1618192021222324 172526272829301 182345678 TodayClear JanFebMarApr MayJunJulAug SepOctNovDec OKCancel PROGRAM CALENDAR MAILING How would you like our program calendar sent to you? Loading… Monthly Calendar Mailing Monthly Calendar Email Org Contact for Calendar Mailing Close EMERGENCY CONTACT INFORMATION Contact Name Relationship Select... Child(ren) Doctor Office Family Member Friend Guardian Parent(s) Religious Official Sibling Significant Other Spouse/Partner Other Home Phone Cell Phone Work Phone REFERRAL How did you hear about us Loading… Doctor Nurse/Nurse Navigator Social Worker Friend/Family Internet TV/Radio Newspaper Social Media Gilda's Club Staff/Volunteer Other Therapist School Close If referred by a healthcare professional, please select the hospital/office that referred you: Loading… UnityPoint Health – Trinity Genesis Iowa Cancer Specialists Other MercyOne University of Iowa Mayo Clinic Close DIAGNOSIS INFORMATIONPlease complete the following for yourself or for the person you are supporting (if applicable). Primary Cancer Type Select... Bladder/Urinary Bone Brain Breast Cervical Colon, rectal Head & Neck Kidney Leukemia Liver Lung Lymphoma Melanoma/Skin Multiple Myeloma Ovarian Pancreas Prostate Stomach Uterine Other All Types of Cancer Loading… Bladder/Urinary Brain Breast Colon, rectal Head & Neck Kidney Leukemia Liver Lymphoma Lung Melanoma/Skin Multiple Myeloma Ovarian/Uterine/Cervical Pancreas Prostate Stomach Other Close Other Type of Cancer Date Diagnosed Loading… April 2021 SunMonTueWedThuFriSat 1328293031123 1445678910 1511121314151617 1618192021222324 172526272829301 182345678 TodayClear JanFebMarApr MayJunJulAug SepOctNovDec OKCancel Are you currently in treatment?YesNo Medical Oncologist Loading… Bender Garneau Constantinou Friemel Chitneni Spector Porubcin Bosquet Goodheart Hill Sy Vakkalanka Other Close If Other, who is your oncologist? Medical Center Loading… Genesis Iowa Cancer Specialists Mayo Clinic MercyOne UnityPoint Health – Trinity University of Iowa Other Close If Other, where are you seen? I give you my permission to let my oncologist know I am attending Gilda’s Club:YesNo DEMOGRAPHICSThe following are optional and are used to help us better understand whom we are serving, and any groups that may be underserved. Marital Status Select... Domestic partnership Coupled Divorced Living with significant other Married Separated Single Widowed Unknown Sexual Orientation Select... Bisexual Gay Lesbian Straight Other Race/Ethnicity Select… White (Non-Hispanic) African-American (not Hispanic) White-Hispanic Black-Hispanic Asian/Pacific Islander American Indian/Alaska Native/First Nations Other Insurance Select… Medicare Only Medicare + Private Medicaid Private Insurance VA Uninsured Type of Employment Select… Full or Part-time On Medical Leave Disabled Not Employed Retired Student Annual Household Income Select… Under $25,000 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 Over $100,000 Education Select... Less than High School High School Graduate or GED Some College or Technical or Vocational School College Graduate Some Graduate School Graduate Degree Post graduate work or degree Unknown Are you active military or a veteran? YesNo