Customized Membership Plan

Customized because you are an individual. Membership because you are not alone. Plan because choices about your needs are taken seriously.

A community for those seeking support through a cancer diagnosis.

Please enter your email address    
Already have an account? Login here

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* 
If you are a support person, what is the name of the person with cancer that you are here to support?
Primary Cancer Type* 
All Cancer Types
v
Medical Center
Dr. Name
Ethnicity
Income
Insurance
Employment
Location of Services (when onsite programming returns)
Referral
v
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?
Please provide Name / Gender / DOB for each child.
Children Program Interests (check all that apply)
v

Emergency Contact

Contact Name* 
Contact Number* 
Relationship* 


 
img
3517 Rochester Road,
Royal Oak, MI 48073
img
248.577.0800
img
Monday - Thursday: 12-8 p.m.
Saturday 12-3 p.m.