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Ou pa ka mete yon pri sou bonè ak byennèt ou. Se poutèt sa rantre nan Cancer Champions se konplètman gratis .

Lè ou rantre nan Cancer Champions, ou jwenn plis pase aksè — ou jwenn yon pwogram pèsonalize ki fèt espesyalman pou bezwen ou yo.

Espesyalis kansè sètifye nou yo ap aprann konnen w, epi kreye yon plan ki sipòte objektif ou yo an tèm de fòm fizik, nitrisyon, ak mantalite pou ou ka santi w pi fò, sipòte, epi gen konfyans, kèlkeswa kote w ye nan vwayaj ou a.

Vin jwenn chanpyon kansè yo

Pou enskri pou vin manm gratis Cancer Champions ou a, tanpri ranpli fòm ki anba a. Enfòmasyon ou yo ap rete an sekirite epi konfidansyèl, epi yo p ap janm pataje oswa vann.

Contact Information

First Name *

Last Name *

Email Address *

Phone *

Gender Identity *

Date of Birth *

Race *

Are you of Hispanic, Latino/a/x, or Spanish origin? *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Approximate Annual Household Income *

Are you a veteran or active-duty service member? *YesNo

Patient Overview

Type of cancer *

Stage of cancer *

Are you currently undergoing treatment? If so, what is it? (chemo, radiation, etc.) *If you are post-treatment or in between treatments, please specify that here.

Do you (or did you) have any metastases? If so, where are/were they located? (Please list them) *

Who is your oncologist?

What is your medical group?

How can we at Cancer Champions support you? *FitnessNutritionMindsetCommunity

Type of InsuranceGovernment-SponsoredPrivateNone(Type of insurance does not affect membership)

Your Care Partner Info

(or Emergency Contact)

Name

Email Address

Phone

Final questions

How did you hear about Cancer Champions? *

Are you interested in being paired with one of our Mentors/Coaches to support you? *Yes, I'd like to learn moreMaybe laterLearn more about how our Coaches can support you by clicking here.

Do you speak English? *YesNo

I agree *

By participating in the Cancer Champions program, you acknowledge and accept the inherent risks associated with physical activity, including the potential for injury. It is your responsibility to consult with a healthcare professional before beginning the program.

Please double-check your info *Please double-check all your information is correct before submitting

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