Skip to content
Program Guide PDFs
Programas en español
Login | Register
About Us
Testimonials
Diversity, Equity, Inclusion and Belonging
Our Programs
Overview
Join a Program
Special Program Events
Webinars & Videos
Support Us
Overview
Ways to Give
Volunteer
Events
Healthcare Professionals
News
Contact
Search for...
Donate
Program Guide PDFs
Programas en español
Login | Register
Search for...
Navigation Menu
Navigation Menu
About Us
Testimonials
Diversity, Equity, Inclusion and Belonging
Our Programs
Overview
Join a Program
Special Program Events
Webinars & Videos
Support Us
Overview
Ways to Give
Volunteer
Events
Healthcare Professionals
News
Contact
Donate
Home
»
Psychosocial Survivorship Training Registration
Psychosocial Survivorship Training Registration
Comprehensive Cancer Psychosocial Survivorship Training
Main
"
*
" indicates required fields
First Name
*
Last Name
*
Pronouns (optional)
Professional Credentials
Name of your agency/organization
Email
*
Phone
*
Address 1
Address 2 (Suite # or Box#)
City
State
Zip Code
1. Does your organization/agency work with people impacted by cancer (cancer survivors, caregivers and loved ones) in underserved populations?
Yes
No
2. Which counties are served by your organization/agency?
3. Which underserved populations do you work with at your organization/agency? (Select all that apply)
Low Income
Racial/Ethnic Minority
Rural
Uninsured and/or Underinsured
Other (Please describe)
Other
Do you have an existing survivorship program at your organization/agency? If yes, please describe the program in a few sentences. If no, what barriers have you encountered in trying to establish a program?
Are you interested in earning CEUs for this training?
Yes
No
The questions below are designed to capture the demographic information of respondents and are optional questions.
Are you of Hispanic, Latino/a/x, or Spanish origin? [Select all that apply]
No, not of Hispanic, Latino/a/x, or Spanish Origin
Yes, Mexican, Mexican American, or Chicano
Yes, Puerto Rican
Yes, Cuban
Yes, another Hispanic, Latino or Spanish origin (e.g., Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian)Mistrust in the medical system
Prefer not to answer
Select All
If another, please, list/describe
What is your race? ([Select all that apply AND specify origin as applicable)
Black or African American
Native American/American Indian/Alaska Native (e.g., Navajo Nation, Blackfeet tribe, Mayan, Aztec)
African (e.g., Nigerian, Ethiopian, Somali)
Caribbean (e.g., Jamaican, Haitian)
Yes, another Hispanic, Latino or Spanish origin (e.g., Salvadoran, Dominican, Colombian, Guatemalan, Spaniard, Ecuadorian)Mistrust in the medical system
Asian American
Asian (e.g., Chinese, Filipino, Indian, Vietnamese, Korean, Japanese Pakistani, Cambodian, Hmong)
Pacific Islander (e.g., Chamorro, Samoan, Native Hawaiian, Tongan, Fijian, Marshallese, Palauan, Tahitian, Chuukese)
White American
European (e.g., German, Irish, English, Italian)
Prefer not to answer
Select All
Prefer to self-describe
How would you describe your gender identity? Select all that apply.
Cisgender
Transgender
Non-Binary
Woman
Man
Prefer not to answer
Select All
Prefer to self-describe
How would you describe your sexual orientation? (Select all that apply)
Asexual
Bisexual
Gay
Lesbian
Pansexual
Queer
Questioning
Heterosexual
Prefer not to answer
Select All
Prefer to self-describe
Untitled
Untitled
Section Break
Δ