Survey - Information Request Form - Colon Cancer Alliance

Please fill out the following contact information

*

Name:

First Required	Last Required

*

Email: Required

Street 1:

Street 2:

City/State/ZIP:

City	State	ZIP

Phone Number:

Date of Birth:

Yes, I would like to receive e-mail from Colon Cancer Alliance

Email Format:

Yes, I would like to receive postal mail from Colon Cancer Alliance

Remember me. What's this?

About Me (Optional)

The following information about yourself and the colorectal cancer patient in your life will help the CCA gather statistics that will aid us in our research and advocacy efforts. Information gathered is strictly confidential and will not be given to outside parties.

Question - Not Required - Which of the following best describes your connection to colon cancer?

Question - Not Required - If Other, please specify:

(Maximum response 255 chars, approx. 5 rows of text)

Question - Not Required - Within the last six months, were you or a loved one diagnosed with colon cancer?

Question - Not Required - Age Group

Question - Not Required - Gender:

Question - Not Required - Race/Ethnicity

Question - Not Required - If Other Race, please specify:

(Maximum response 255 chars, approx. 5 rows of text)

Buddy Program

One important service the CCA offers is the opportunity for the newly diagnosed, their families, and their friends to speak to others who have been there. Buddies are survivors and caregivers who share their own stories. Buddies provide the personal perspective, whether it is coping with side effects, treatment options, life after a colostomy or dealing with the many emotional issues that come with this illness.

Question - Not Required - I would like to:

	Get more information about the Buddy Program
	Help somebody through their journey
	Be matched with a buddy to help me through my journey

CCA's My CRC Connections, Online Community

My CRC Connections is a peer support group for colorectal cancer patients and their loved ones with almost 2,000 members. We don’t offer professional counseling - just lots of hugs, advice and support from people who share similar experiences and emotions.

Question - Not Required - I would like to:

Receive more information about CCA's My CRC Connections Online Community

Local Chapters and Ambassadors

Local Chapters and Ambassadors help the CCA fulfill its mission at the local level. Chapters work together as a board while Ambassadors are individuals reaching out to the community.

Question - Not Required - I would like to:

	Be contacted by my local CCA chapter
	Receive information on starting a local chapter
	Receive information on becoming an Ambassador

Get Involved

Question - Not Required - I would like to:

	Hold a special event to benefit CCA
	Share my story with others