Participant Forms If you are a human and are seeing this field, please leave it blank. Fields marked with a * are required. Name * Email * Phone * Program Attending * If you are new to The Cancer Support Center please fill out the questions below (existing participants can skip to the next section) Address Cancer Type Hospital for Treatment Participant Type (Survivor, Caregiver, Bereaved) Please check each box below to acknowledge your consent for each of the following: (By submitting your registration you agree to The Cancer Support Center's Use of Service Agreement for any programs offered on-site or online) Use of Services – Cancer Support Center programs are offered at no charge to any participant. Our intent is to provide a safe environment and programming that is beneficial to those involved. We expect participants to discuss concerns with appropriate staff and to hold all associated with the Center harmless in their work to provide programming along professional and ethical guidelines. The Cancer Support Center reserves the right to refuse or to discontinue the privileges of these services to any person. * Wellness Classes—I understand that wellness classes by The Cancer Support Center (including yoga, fitness and massage) include physical movements and that the risk of injury, even serious or disabling, is always present and cannot be entirely eliminated. If I experience any pain or discomfort, I will listen to my body and ask for support from the staff. * Medical Assistance/Advice – The Cancer Support Center and its staff members do not provide medical advice or assistance. None of our programs are a substitute for medical attention, examination, diagnosis, or treatment. They may not be recommended and safe under certain medical conditions. I affirm that I alone am responsible to decide whether to practice wellness classes and will discuss my choices with my physician if I am unsure about my safety. I hereby agree to irrevocably release and waive any claims that I have now or hereafter may have against The Cancer Support Center and staff. * Nutrition Pop-Up Station- I understand that I alone am responsible for my participation in any Nutrition POP-Up Station at The Cancer Support Center. I hereby release The Cancer Support Center and Center for Food Equity in Medicine from any liability should I become ill as a result of my participation in this program. If you are a human and are seeing this field, please leave it blank.
