Member Record Form - Crossroads4Hope

"*" indicates required fields

Crossroads4Hope is a nonprofit organization funded solely through donations and grants. All of our services are offered at no charge for anyone affected by cancer. By providing your information, we are able to track participation for the purpose of improving programs and obtaining funding. All information is kept strictly confidential and secure.

If you need assistance completing the form, please contact us at 908-658-5400.

THIS FORM IS INTENDED FOR ADULT INFORMATION ONLY.

Contact Information

Date

Name*

First Middle Last

Address*

Street Address City State ZIP Code

County

Primary Phone*

Type*

Home

Mobile

Work

Secondary Phone (Optional)

Type

Home

Mobile

Work

Hidden

Mobile Passthrough (Hidden)

Email*

Enter Email Confirm Email

By providing your email address we will send program communications. Would you like to receive a mailed calendar?*

Yes

Emergency Contact Name*

First Last

Relationship*

You selected “Other.” Please describe:*

Phone*

Member Information

I am a:*

Person with cancer

Family/friend of person with cancer

Person in bereavement

Parent of child diagnosed

Previvor: person worried about my cancer risk

Other

You selected "Other". Please describe:*

The information you submit is completely confidential. If you are uncomfortable disclosing any information in this section, please leave it blank.

Cancer Diagnosis

You selected "Other", please indicate the cancer diagnosis here:*

Date of Diagnosis

Diagnosis Type

New (First time diagnosed)

Recurrent

Is your cancer:

Early stage

Advanced or metastatic

Treatment Stage:

Active

Post

Oncologist Name

First Middle Last

Cancer Center/City

If you have any health problems or medical history you feel we should know about, please list:

If you have any allergies we should know about, please list:

Relationship to person with cancer:*

You selected "Other", please indicate your relationship here:*

Relationship*

Bereavement of child

Bereavement of family member

Bereavement of friend

Date of loss*

Section Break

Demographic Information

The information you submit is completely confidential. If you are uncomfortable disclosing any information in this section, please leave it blank.

Date of Birth*

Veteran or an active duty service person?

Yes

Years Served

Relationship Status

Single

Married

In a civil union

Domestic partnership or living together

Partnered, not living together

Divorced

Widowed

Other

You selected "Other". Please describe:*

Race/Ethnicity

White (non-Hispanic)

White (Hispanic/Latino)

Black/African American (non-Hispanic)

Asian/Pacific Islander

South Asian

Black-Hispanic

American Indian/Alaska Native/First Nation

Other

You selected "Other", please indicate your race/ethnicity here:*

Preferred Language Spoken (other than English):

Gender Identity

Male

Female

Transman

Transwoman

Genderqueer/Non-binary

Additional Category

Decline to answer

You selected "Additional Category". Please describe:*

Sexual Orientation

You selected "Additional Category". Please describe:*

Pronouns

She/Her/Hers

He/Him/His

They/Them/Their

Additional Pronoun(s)

You selected "Additional Pronoun(s)". Please describe:*

Number in Household

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

Yes

Please click "add child" to add additional details below

Child Name	Child Age	Actions

There are no Children.

Employment Status

Full Time

Part Time

Medical Leave

On Disability

Not Employed

Retired

Occupation

Employer

Insurance

Private (incl. ACA)

Uninsured

Medicare

Medicare & private

Medicaid

Medicaid/Medicare

Annual Family Income

Under $25,000

$25,000 – 49,999

$50,000 – 74,999

$75,000 – 99,999

$100,000+

In the last 12 months, did you ever eat less than you felt you should because there wasn’t enough money for food?

Yes

Are you worried that in the next 2 months, you may not have stable housing?

Yes

Do problems getting child care make it difficult for you to work or study?

Yes

In the last 12 months, have you needed to see a doctor, but could not because of cost?

Yes

In the past 12 months has lack of transportation kept you from medical appointments, meetings, work, or getting things for daily living?

Yes

Do you ever need help reading hospital materials?

Yes

Do you often feel that you lack companionship?

Yes

How did you hear about Crossroads4Hope?

Program flyer/calendar

Friend/family

Crossroads4Hope member

Healthcare professional/institution

Health Fair/Community Event

Online/Search Engine

Print/Press Release

Social Media

Other

You selected "Other", how did you hear about Crossroads4Hope?*

[By submitting this form,] I agree to take full responsibility for not exceeding my personal limits in the practice of a Health and Wellness program and for any injury I might suffer during my participation in classes with Crossroads4Hope. It is my responsibility to ascertain that there is no medical reason to prevent my participation in this activity and to abide by any limitations that might be set by my medical providers. I do hereby agree for myself, my heirs, assigns, executors and administrators (and for any other party who may claim under or through me) to RELEASE, ACQUIT, WAIVE, DISCHARGE and FOREVER HOLD HARMLESS Crossroads4Hope, its officers, directors, employees, agents, volunteers, affiliates, all partner agencies, subsidiaries and predecessors from any and all claims, demands, costs, expenses, rights and causes of action of any kind and nature whatsoever at law or in equity on account of all foreseen or unforeseen injuries and damages resulting from my participation in any classes with Crossroads4Hope.