New Membership Form

We 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.

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GENERAL INFORMATION

Location of Form Completion
Employer
Do you have children under 18?
I am registering as a:
If a support person, who are you here to support?
If a bereaved person, when did your loved one die?
v

PROGRAM CALENDAR MAILING

How would you like our program calendar sent to you?
v

EMERGENCY CONTACT INFORMATION

Contact Name
Relationship
Home Phone
Cell Phone
Work Phone

REFERRAL

How did you hear about us
v
If referred by a healthcare professional, please select the hospital/office that referred you:
v

DIAGNOSIS INFORMATION

Please complete the following for yourself or for the person you are supporting (if applicable).

Primary Cancer Type
All Types of Cancer
v
Other Type of Cancer
Date Diagnosed
v
Are you currently in treatment?
Medical Oncologist
v
If Other, who is your oncologist?
Medical Center
v
If Other, where are you seen?
I give you my permission to let my oncologist know I am attending Gilda’s Club:

DEMOGRAPHICS

The following are optional and are used to help us better understand whom we are serving, and any groups that may be underserved.  

Marital Status
Sexual Orientation
Race/Ethnicity
Insurance
Type of Employment
Annual Household Income
Education
Are you active military or a veteran?

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