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Survivor University
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Main Content
Survivor University Application
*
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First Name
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Middle Initial
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Last Name
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Preferred Name (what you like to be called)
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Street Address
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City/State/Zip
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City
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Primary Phone Number
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Alternate Phone Number
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Caregiver Name (if one is attending)
Caregiver Phone Number
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Caregiver Email Address
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Survivor University is intended for individuals who have received a cancer diagnosis in the past 6 months. What date did you receive a cancer diagnosis?
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Survivor University is an online program. Do you have internet access and electronic equipment available to participate in the training (computer, tablet, mobile phone, webcam)?
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Yes
No
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What is the site or with what type of cancer have you been diagnosed? (select all that apply)
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Bladder
Breast
Cervix
Colon
Head and Neck (including oral)
Kidney
Leukemia
Liver
Lung
Myeloma
Non-Hodgkin's Lymphoma
Ovary
Pancreas
Prostate
Stomach
Skin (melanoma)
Thyroid
Uterus
Other
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If Other, please describe.
Please describe what you hope to learn or accomplish through the training.
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Please describe how you learned about Survivor University.
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Is there anything else you would like for us to know, or any question you may have?