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Online Support Group Registration Form

Registration Form

Computer Equipment Requirements:
In order to participate in this group you will need an e-mail address or a graphical web browser, such as Netscape or Explorer. If you choose to use the web version, you will also need an Internet service provider, such as America Online or CompuServe. There are local Internet providers as well.

To Apply:
Please fill out the form below. Only the group facilitators, Jan Locher, Linda Abbott, Joan Felkner and Keri Mercer, will have access to this form.

(* = Indicates required field)

* First Name:

* Last Name:

* Street Address:

* City:

* State:

County:

* Zip Code:

* Area Code & Telephone:

* Email:

* Your Diagnosis:

* Current or Recent Treatment:

* Previous experience in support groups?
Yes
No

If Yes, what types of groups have you participated in? (This question is optional.)

* Do you receive cancer care at The University of Iowa John and Mary Pappajohn Clinical Cancer Center?
Yes
No

* Would you like to receive information about becoming a patient at The Holden Comprehensive Cancer Center at The University of Iowa?
Yes
No

Comments:

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Last modification date: Wed Aug 8 11:42:10 2007
URL: http://www.uihealthcare.com /depts/cancercenter/support/registration.html