Membership Form – TWCF The Warwick Cancer Foundation Members If you are a young adult with cancer, you can become a member and be eligible for all our support programs. Contact us today! Name First Last Marital StatusPhoneMobileEmail D.O.B AgeNumber Of ChildrenSexMaleFemaleAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Best Contact Time : HH MM AM PM Best Form Of ContactPreferred Contact Name First Last What are your hobbies / interests? Diagnosis Date Of DiagnosisMain Treating HospitalPlease provide a summary of your experience Please provide a summary of your treatment regime What kind of support are you looking for? How did you hear about the Warwick Cancer Foundation Emergency ContactName First Last Relationship To MemberHome PhoneMobileQuite often, new members request to be put in contact with other young adults diagnosed with cancer. Our Mates in My Shoes program connects members who are experiencing the same types of issues that arise from cancer diagnosis. Issues such as, financial instability, treatment side effects, fertility, relationships are some of the topics that are discussed amongst members. We only connect members who are willing participants and never disclose contact or personal information between members. Should you wish to participate in the Mates in My Shoes program, The Warwick Cancer Foundation would contact you advising of the request to connect. Please indicate if you would be willing to be connected to other members who are seeking peer support. InterestedYesNoTHE WARWICK CANCER FOUNDATION IS BOUND BY STATE AND FEDERAL INFORMATION PRIVACY LEGISLATION AND IS COMMITTED TO SUPPORTING THE “NATIONAL PRIVACY PRINCIPLES FOR THE FAIR HANDLING OF PERSONAL INFORMATION”, WHICH SET CLEAR STANDARDS FOR THE COLLECTION, ACCESS, STORAGE AND USE OF PERSONAL INFORMATION WHICH IS OBTAINED AS PART OF NORMAL OPERATIONS. THE WARWICK CANCER FOUNDATION RESPECTS MEMBERS RIGHT TO PRIVACY OF THEIR PERSONAL AND CONFIDENTIAL INFORMATION AND WILL DO EVERYTHING POSSIBLE TO PROTECT INFORMATION FROM UNAUTHORISED ACCESS, LOSS OR MISUSE. THE POLICIES AND PROCEDURES AIM TO ENSURE THAT ALL PERSONAL INFORMATION, NO MATTER HOW OR WHERE IT IS OBTAINED, IS HANDLED SENSITIVELY, SECURELY, AND IN ACCORDANCE WITH THE NATIONAL PRIVACY PRINCIPLES.