CINJ Survivors' Action League

Registration Form

Many patients, patients’ friends and family members express wanting to do something to help in the fight against cancer. This includes: advocacy, writing letters, assisting other patients, public speaking and other activities. CINJ's Center for Cancer Survivorship will be asking all survivors (including patients, caregivers and friends) who want to become involved to register with the CINJ Survivors' Action League. Based on the interest and energy of this group we will work to focus our collective energies and make an impact on survivorships issues. The mission of the Survivor Action League is to mobilize and empower cancer survivors to improve the quality of life for all survivors.

Join our league and be a part of our mission. Please fill out this form with your information and describe your interests to join the CINJ Survivor Action League.

Name:
Address:
City:
State:
Zip:
Phone(Day):
Phone(Evening):
Best Time to Contact:
E-mail:
Preferred Method of Contact:
Race:
Ethnicity:
Sex: M F

Please indicate other ways that cancer has touched your life:
I am/was a caregiver for someone who has/had cancer
I have a friend who has/had cancer
I have a relative who has had cancer
I have received a diagnosis of cancer


If you have had a diagnosis of cancer, please indicate which type below
(check all that apply)
Bladder
Breast
Colorectal
Lung
Non-Hodgkin Lymphoma
Ovarian
Prostate
Testicular
Uterine
Other (Please Specify)

What year were you diagnosed?
Are you currently under active treatment?
(excluding hormone therapy)		 Yes
Were you treated at CINJ? Yes No

I am interested in activities related to: (Please check all that apply)
Clinical trials
Advocacy
Quality of Life
Support Programs (Educational Programs, Events that foster support/healing opportunities for survivors and caregivers)
Fundraising Events (runs, walks, etc.)
Cancer Prevention
Cancer Awareness (speaking about my experience)


What languages do you speak other than English?
Spanish
French
Swedish
Dutch
Vietnamese
Hindi
Haitian Creole
Portuguese
Gujarati
Korean
Arabic
Urdu
Chinese
Japanese
Other (Please Specify)
What is your level of fluency?
Beginner
Intermediate
Advanced

CINJ is a participating with several community partners in the planning of the New Jersey Summit on Cancer Survivorship. This event is scheduled to take place on November 16-17, 2009. The goal of this event is to develop a five-year statewide action plan to better meet the needs of NJ cancer survivors. Invitations will be extended to health care professionals, patient groups, advocacy groups and public health groups across the state. We would like your feedback about what issues you feel are important to address in this forum and to include in the statewide action plan.

If you are interested in attending the NJ Summit on Cancer Survivorship on behalf of a community or patient organization that you are involved in please indicate this below. Also, include the organization you would represent.

Please let us know about your inspiration for joining the Survivor Action League

If there is other information you think we should know about you or if you have any other comments, please write below.