New Member Interest Form

Please complete this form if you are interested in Cancer or Grief Support at Gilda's Club Grand Rapids or Gilda's Club Lowell. A member of our program staff will contact you with more information. If you have any questions please call us at 616-453-8300, toll free at 1.800.326.1419, or email us at [email protected]

Name*

First Last

Email*

Phone

Date of Birth*

Zip Code*

Gender

I am interested in programs at the following Gilda's Club location:

Grand Rapids
Lowell

Cancer Support Interest

Please complete this section if you are interested in receiving information about our cancer support programs. Leave blank if this does not apply to you (Grief Support info below).

Select all that apply.

I am living with cancer.
I have a family member or friend living with cancer.
I would like more information about the Youth Cancer Support Program.

Type of Cancer:

Date of Diagnosis:

Are you interested in bringing a child/teen to our Youth Cancer Support Program?

Yes
No

If yes, what is the Youth's names and ages?

Please use this space to provide additional information about your cancer journey:

Grief Support Interest

Please complete this section if you are interested in receiving information about our grief support programs. Leave blank if this does not apply to you.

Select all that apply.

I would like more information about the Youth's Grief Support Program.
I would like more information about Adult Grief Support.

Who in your life died?

When did the death occur?

Cause of death: if cancer, what type?

Are you interested in bringing a child/teen to our Youth Grief Program?

Yes
No

If yes, what is the child/teen's names, ages, and who in their life died?

Please use this space to provide any additional information about your grief journey: