Member Registration

If you don’t have a Mobile please indicate your Home or Business Phone in the required field.

Choose a Photo Cancel

MEMBER INFORMATION

This information helps us find the most appropriate support services for you as well as help us to continue expanding our offerings. Your information will be kept confidential with GCW program staff and will not be used for donor or advertisement purposes. Your answers to these questions will in no way affect your ability to access our free programs. Aggregate demographic information also helps us to secure funding through donations and grants which fund our programs. Specific information is never shared.

Preferred Language Select... English Spanish Participant Type*  Select… I am actively living with a cancer diagnosis. I am Post-Treatment (PT) from cancer within 5 years. I am actively caring for a person living with cancer. I am grieving the death of a loved one from cancer within 5 years. I am a health care professional. None of the above are applicable. Primary Cancer Type Select... N/A - Health Care Professional Bladder/Urinary Blood Bone Brain Breast Cervical Colon, rectal Gynecologic Head & Neck Kidney Leukemia Liver Lung Thyroid Lymphoma Melanoma Multiple Myeloma Ovarian Pancreas Prostate Stomach Other Uterine Medical Center N/A Columbia (NYC) MSK-NYC MSK-Harrison NYPL NYP (City) NYU Langone WESTMED WPH Other All Types of Cancer Loading… N/A - Health Care Professional Bladder/Urinary Blood Bone Brain Breast Cervical Colon, rectal Gynecologic Head & Neck Kidney Leukemia Liver Lymphoma Lung Thyroid Melanoma Multiple Myeloma Ovarian Pancreas Prostate Stomach Uterine Other Close Oncologist Type of Employment Select… Full or Part-time On Medical Leave Disabled Not employed Retired Student Employer Occupation Ethnicity Select… White(Non-Hispanic) African-American (not Hispanic) White-Hispanic Black-Hispanic Asian/Pacific Islander American Indian/Alaska Native/First Nations Other Income Select… Under $25,000 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 Over $100,000 Insurance Select… Medicare Only Medicare + Private Medicaid Private Insurance Uninsured VA Health Care Language English Spanish Other Referal Source Select… Doctor Nurse/Nurse Navigator Social Worker Friend/Family Internet TV/Radio Newspaper Social Media CSC Staff/Volunteer Other Children Under 18*  YesNo If you have children/grandchildren under 18, please provide Name / Age / Gender / DOB 0/1000 characters Please check here if you are interested in learning more about our children, teens and families program.

EMERGENCY CONTACT