Phoenix Survivor Network Membership Application Form
All of the information provided will be kept confidential and will only be used to recommend the best programs to fit your needs.
Please tell us about yourself
Name
Address
City/Town
State | Zip Code
Email
EMERGENCY CONTACT
Name | Relationship
Phone Number:
How did you hear about Phoenix Survivor Network? Survivor/ThriverSocial MediaFamily/FriendMedical ProfessionalOther (please explain)
Gender FemaleMale
Race/Ethnicity (optional) American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or Other Pacific IslanderWhiteOther (please specify)
Your Age Group 14-2122-3031-4041+
Date of Birth
*Are you a breast cancer survivor? YesNo
Are you living with Metastatic Breast Cancer? YesNo
Are you a survivor of another type of cancer? YesNo
If yes, please specify:
Are you a (select all that apply): Family member of a breast cancer survivorFriend of a breast cancer survivorCaregiver of a breast cancer survivorHigh risk for breast cancerBereavedOther (please specify)
Do you have child(ren) under the age of 18? YesNo
If so, please list each child’s gender and age:
Phoenix Programs Please select your programs of interest:
Talk Circles (talk therapy) IndividualGroup
The Journey Newly diagnosedPost TreatmentLong Term
The Temple YogaTai ChiBell DancingBoxingMarital ArtsSteppingLine DancingWalk Away the WorryZumbiMassage TherapyHealthy eating classes & demonstrationsFlame On Peer Buddy ProgramPrayed Up nondenominational pray groupParenting GroupsBook Talks
Creative Corner CeramicsJewelry makingWoodworkPaintingDigital art/PhotographyMoney Matters
One Girl, One Boy (youth programs, ages 5-17)
List other programs you would like PSN to offer
Member Signature : Date:
