Blood Cancer Support Group (Ventura/Oxnard) Registration

Please have each patient, caregiver, family member or friend

who will be attending register individually.

First Name *

Last Name *

Street Address *

Address Line 2

City *

State/Province/Region *

Zip/Postal Code *

Email Address *

Preferred Phone Number *

Phone Type *

I am a: *

Familial Relationship to Patient *

If Other, please specify *

Diagnosis Date of Patient +

Patient’s Date of Birth (MM/DD/YYYY) *

My or my loved one's diagnosis is: *

Leukemia Disease Type *

Lymphoma Disease Type *

Myeloma Disease Type *

MDS Syndrome *

Myeloproliferative Neoplasms Disease Type *

Other Blood Cancer Disease Type *

With which race(s) do you identify? (Select all that apply) *

Do you identify as Hispanic, Latino or Spanish origin? *

Yes

No

Prefer not to answer

Please specify your gender. *

Female

Male

Another gender

Prefer not to answer

Have you ever served on active duty in the U.S. Armed Forces, Military Reserves, or National Guard? *

Yes

No

Prefer not to answer

Do you have any questions or comments you would like to include? *

Do you have questions about your disease, treatment or resources and would like a call from an LLS Information Specialist to discuss them? *

Yes

No