MyGo2Support Program Enrollment

As a member of the Crossroads4Hope community, you are eligible to join the MyGo2Support program! MyGo2Support is a new resource designed to extend support outside of Crossroads4Hope and keep members connected within the community. Members receive messages in the form of text messages that are personalized to meet the member’s specific needs, offering educational information, tips, information regarding sessions, events and more. If at any point you would like to unsubscribe from the program, all you have to do is text the word STOP and you will stop receiving messages. Text messages will be a part of your existing text plan. So, after you opt in, if a message does pop up regarding additional fees, do not worry; there are no additional fees associated with this program. This program is free, and your information will be kept totally private.

Member Name*

First Last

Salesforce ID

Mobile Number*

Email*

Enter Email Confirm Email

Address*

Street Address City State ZIP Code

Hidden

County

Gender Identity*

Male
Female
Transman
Transwoman
Genderqueer/Non-binary
Additional Category
Decline to answer

You selected "Additional Category". Please describe:*

Date of Birth*

Must be 18 years or older

Hidden

AGE CALC (HIDDEN)

I am a...*

Person with cancer
Family/Friend of person with cancer
Person in bereavement
Previvor: person worried about my cancer risk

Tell us a little about yourself

My cancer is/was*

Early Stage
Advanced or metastatic

My diagnosis is/was:*

New (First time diagnosed)
Recurrent
Post treatment

Tell us about your relationship

Relationship to person with cancer:*

My child’s cancer is/was*

Early stage
Advanced or metastatic

My child’s diagnosis is/was:*

New (first time diagnosed)
Recurrent
Post treatment

My child's age*

Tell us about your relationship

Relationship*

Bereavement of child
Bereavement of family member
Bereavement of friend

Date of Loss*

Just a few more things

I am a parent raising a child under the age of 19…*

Yes
No

What language would you like to receive program messages in?*

English
Spanish

We’re just about done signing you up. Once I complete your enrollment, you will receive a confirmation text message containing a link that will take you to the program terms and conditions, as well as some HIPAA information for you to read through. With that being said, I do need you to confirm that you understand that text messages are not considered secure technology and that the messages you receive may indicate the nature of yours/ your loved one’s condition. However, beyond the general nature of the condition, this program does not send Protected Health Information (PHI) via text. Text messages are used from your text plan but there are absolutely no additional charges.

Do you accept?*

Consent for HIPAA Waiver and program Terms and Conditions

Enrolled by*

First Last