CSCAZ gathers information about every member to help us better understand who comes to our programs. All personal information will be kept confidential. CSCAZ is a non-profit organization that offers our program at no cost to our participants. We rely solely on donations to underwrite our programs, and we use the following information to help us secure funding. The information provided to funders will be only in terms of combined demographic data of all participant with no identifying information. Your answers to these questions will, in no way, affect your ability to access all services at CSCAZ at no charge.

YOUTH / TEEN INFO PLEASE PRINT CLEARLY. THANK YOU!

Date:

Last Name: First Name:

Address: City: State: Zip:

Phone:(HM) (CELL)

Email: Facebook Profile Name:

(IN CASE OF EMERGENCY)Parent/Guardian name: Phone:

  • May we use your mail, email address, phone number or Facebook for correspondence about other upcoming

programs andspecial events? Mail:  Yes  No Email:  Yes  No Phone:  Yes  No Facebook:  Yes  No

PLEASE COMPLETE THE FOLLOWING ABOUT YOUTH / TEEN:

Is this the first time that you have attended one of our programs? Yes No

If no, what year is the first year you attended a program?

I came here because I am a Person with Cancer/Survivor I am a Support Person/Caregiver (Family, Friend)  Other

Cancer Diagnosis(es) impacting myself or my loved one:

Where did/do you or your loved one receive the majority of treatment?

Gender:  M  F Date of Birth: Age: 0-6 7-12 13-17

I attend:(check one)  grade school (grade level)  middle school (grade level)  high school (grade level)

Name of School  homeschooled  not currently in school

Ethnicity:White (not Hispanic) Black/African American (not Hispanic) White - Hispanic  Black – Hispanic  Asian/Pacific Islander

 American Indian/Alaska Native/First Nations  Other

Type of Insurance:Uninsured Medicare only  Medicare + Private  Medicaid/AHCCCS  PrivateInsurance (list):

Number in household:

How did you hear about CSCAZ? Friend/Family Internet  Community Organization Healthcare Professional  Health Fair/Expo

PLEASE BE SPECIFIC: Name of person who referred you

Title Hospital/Office City/State

  • I understand that photos may be taken of the minor and myself at certain events and allow CSCAZ to use these photos for legitimate purposes. Initial:
  • I attest that I am the legal guardian of above named minor and that I am voluntarily enrolling the minor to participate in the program services offered by Cancer Support Community Arizona. I hereby assume all related risks and release any liability of CSCAZ and its representatives for any injury or property damage that may occur.

Signature: Date:

Cancer Support Community Arizona360 East Palm Lane Phoenix, AZ 85004 Phone: (602) 712-1006