Customized Membership Plan

Choose a Photo Cancel

Your birthdate is requested to identify age brackets we serve, for program development and grant applications. Along with your personal information, is it absolutely never shared.

Member Details

Member Type*  Select... Person with Cancer Support Person Bereaved If you are a support person, what is the name of the person with cancer that you are here to support? Primary Cancer Type*  Select... Bladder/Urinary BoneConnective Tissue Brain Breast Carcinoid Cervical Colon/ rectal Endometrial Cancer Esophagus Gastrointestinal Head and Neck Kidney Leukemia Liver Lung Lymphoma Melanoma Multiple Myeloma Oral Ovarian Pancreas Prostate Sarcoma Stomach Testicular Thyroid Uterine Other All Cancer Types Loading… Bladder/Urinary BoneConnective Tissue Brain Breast Carcinoid Cervical Colon/ rectal Endometrial Cancer Esophagus Gastrointestinal Head and Neck Kidney Leukemia Liver Lung Lymphoma Melanoma Multiple Myeloma Oral Ovarian Pancreas Prostate Sarcoma Stomach Testicular Thyroid Uterine Other Close Medical Center Select... Ascension Crittenton Ascension St. John - Moross Ascension - Genesys Hospital Ascension Providence - Novi Ascension Providence - Rochester Ascension Providence - South Lyon Ascension Providence - Southfield Ascension St. John - Macomb Beaumont - Dearborn Beaumont - Farmington Hills Beaumont - Grosse Pointe Beaumont - Health System Beaumont - Troy Beaumont - Royal Oak DMC DMC - Children's Hospital of Michigan DMC - Harper Hospital DMC - Huron Valley Hospital DMC - Sinai Grace Hospital Henry Ford - Macomb Henry Ford - Main Henry Ford - Troy Henry Ford - West Bloomfield Henry Ford - Wyandotte Karmanos Cancer Center McLaren McLaren - Macomb Mclaren - Oakland Other Pontiac General Hospital St. Joseph Mercy Health System - Ann Arbor St. Joseph Mercy Health System - Chelsea St. Joseph Mercy Health System - Livonia St. Joseph Mercy Health System - Pontiac University of Michigan VA Medical Center Dr. Name Ethnicity Select… African American Alaskan/Native American Caucasian Hispanic/Latino American Indian Asian/Pacific Oriental Chaldean Middle Eastern Multiracial Other Not Specified Income Select... Under $25,000 $25,000-$49,999 $50,000-$74,999 $75,000-$99,999 Over $100,000 Insurance Select... Medicare + Private Medicaid/MediCal Private Insurance Medicare Only Uninsured Employment Select... Full or Part-time Retired On Medical Leave Disabled Not Employed Student Location of Services (when onsite programming returns) Royal Oak Clubhouse Lake House Durfee Beaumont Dearborn Beaumont Farmington Hills Select... Referral Loading… Doctor Nurse Social Worker Family/Friend Newspaper TV/Radio Internet Gilda's Club Staff/Volunteer Other Close Referral Other If you were referred by a health care professional, please list their name, hospital/office, city. Do you have children/grandchildren under the age of 18 that you would like to become members as well? YesNo Please provide Name / Gender / DOB for each child. Children Program Interests (check all that apply) Loading… Kids Support Group (age 5-8) Kids Support Group (age 9-12) Teen Support Group (age 13-17) Kids Grief Group (age 5-12) Teen Grief Group (age 13-17) Kids Creative Art (age 5-12) Club Red (teen volunteer group, age 13-17) Close

Emergency Contact