First Last Address (Required) Are you comfortable having your picture taken? (Required) Yes No Are you comfortable telling your story? (Required) Yes No Photo and Media Release (Required) I consent to the photo and media release.
PHOTO AND MEDIA RELEASE: I consent and authorize Cancer Pathways Midwest to use, as they see fit, any and all media obtained during the CPM Ambassador Photo Shoot in broadcast, publicity, public service announcements, social media, training, teaching, research, podcasts, and educational publications both in print and online, and other uses. This may include photographs, videos, recordings, and re-recordings.
What is the best way to contact you? (Required) Phone (Required) Can we text you? (Required) Email (Required)
Emergency Contact (Required)
Please list the name of your emergency contact.
Relationship to Emergency Contact Emergency Contact Phone Number (Required) Do you have any allergies or food preferences? (Required) What is your t-shirt size? (Required) What allergies or food preferences do you have? Tell Us About the Cancer Journey I am a (Required) If you are a person living with cancer, are you currently Name of person with cancer Cancer Diagnosis (Required)
What type of cancer were you or your loved one diagnosed with?
Date of Diagnosis
MM slash DD slash YYYY Age of Diagnosis Treatment Types (Required)
Please check all boxes that apply to your (or your loved ones) cancer treatment
Current Stage of the Disease (Required)
What stage of cancer are you or your loved one currently in?
Treatment Hospital Primary Cancer Treatment Specialist In 1-2 short paragraphs, tell us your story and what you would want others to know about Cancer Pathways: (Required) Consent (Required) By checking this box, I acknowledge I have read this form in its entirety, understand its content and agree to the terms and conditions set forth below.
PRIVACY AND CONFIDENTIALITY: I understand that CPM is a community of many people and will make every attempt to respect my privacy. I will not share others personal information outside of CPM.
PERMISSION TO CONTACT MEDICAL PROVIDERS AND EMERGENCY CONTACTS: If a critical health situation arises while onsite at CPM or offsite at a partner location; I give permission to contact my listed emergency contact(s) and/or my physician. PARTICIPANT RELEASE OF LIABILITY FOR PROGRAM ACTIVITY: As a participant of CPM, it is my responsibility to ascertain that there is no medical reason to prevent my participation in program activities and to abide by any limitations that might be set by my medical providers. I agree to take full responsibility for not exceeding my personal limits and for any injury I might suffer during my participation at CPM or offsite partner location. I do hereby agree for myself, my heirs, assigns, executors and administrators (and for any other party who may claim under or through me) to RELEASE, ACQUIT, WAIVE, DISCHARGE, and FOREVER HOLD HARMLESS, Cancer Pathways Midwest, its officers, directors, employees, agents, volunteers, affiliates, all partner agencies, subsidiaries and predecessors from any and all claims, demands, costs, expenses, rights and causes of action of any kind and nature whatsoever at law or in equity on account of all foreseen or unforeseen injuries and damages resulting from my participation in any program activities provided by CPM and coming to or upon leaving any such activities. This includes program activities held onsite at CPM’s clubhouse and offsite at partner locations.