Name (Optional)
Email Address (optional)
Are you a cancer survivor?
Yes
No
Which of the following programs are you most interested in attending?
Making Crafts
Sports/Physical Activity
Support Group Discussion with a Speaker
Weekend Get-A-Way
Scavenger Hunt
Other
What can Cancer Survivors Unite do to interest you in attending our monthly programs?
Offer Incentives
Provide Transportation
Provice Free/Low Cost Programs
Other
Which factor would deter you from attending one of Cancer Survivor Unite's programs?
Location/Transportation
Cost
No Interest in Program
All of the Above
None of the Above
Please list three programs you would be interested in participating in through the Cancer Survivors Unite organization:
What days & times are you available to participate in a Cancer Survivors Unite Program and/or Fundraising Event?
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Times Available
Are there additional resources you would like to see on our website? Other comments?
Indicates Response Required
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