Register | Wellspring Chinguacousy

Your Wellspring Centre: Wellspring Chinguacousy[change location]

This centre will be your home Wellspring centre but you may also attend programs at other centres. If you would like to choose a different home centre, you may select a location.

Title

First name

Last name

Gender Male Female Other

Date of Birth

Year

Month

Day

You are registering with Wellspring because you are: (check all that apply) a cancer patient a family member or friend caring for a cancer patient at this time someone who has recently lost a loved one to cancer a volunteer

Email (this will be your username)

Please create a password

Please confirm your password:

How did you first learn about Wellspring?

Your Home Address

Street Address

Apt./Suite

Country

City

Postal Code

Province

Zip Code

State

Home Number

Mobile Number

Work Number

Please select your preferred phone number *

Emergency Contact Information:

First name Last name Phone No emergency contact information available.

If you are a cancer patient, please answer the following questions about your diagnosis.

If you are a caregiver of a cancer patient, please answer the following questions about the diagnosis of the person for whom you are caring.

Sometimes, people come to Wellspring who have cancer, and are also caring for a friend or family member with cancer. If this applies to you, please complete the following information based on your diagnosis.

Date of most recent diagnosis:

Is the cancer metastatic?

Metastatic cancer, also known as mets, is cancer that has spread from the primary cancer site to other parts of the body.

Yes No Don't know

Please choose the sentence below that best describes the current status of the diagnosis: Newly diagnosed and the treatment plan is still being determined Currently in treatment Finished surgery, chemotherapy or radiation, and on a follow-up schedule Other, please describe:

Is this the first diagnosis of cancer?

Primary Hospital receiving treatment at:

If applicable

Second Hospital receiving treatment at:

Third Hospital receiving treatment at:

You are registering at Wellspring because of the loss of a:

The cancer patient for whom I am a caregiver is my:

Do you have children under the age of 18? *

Wellspring supports the entire family, and has specialized programming for families with young children. In order for Wellspring to anticipate demand to grow these programs, and to let you know of new programs as they are developed, we are asking to know the number, and ages, of young children you have. No other information about your children is being requested.

Yes No

If your child(ren) and/or spouse will be attending Wellspring programs, they must also be registered. Please register them by completing the information below.

First name

Last name

Gender Male Female

Date of birth:

Year

Month

Day

Is this family member a cancer patient? Yes No

This family member is a: Spouse Child

Add another family member?

Wellspring Chinguacousy

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New Member Form: Step of 5

Your Home Address

Emergency Contact Information:

Monday	9 a.m - 5 p.m.
Tuesday	9 a.m. - 5 p.m.
Wednesday	9 a.m. - 5 p.m.
Thursday	9 a.m. - 5 p.m.
Friday	9 a.m. - 5 p.m.
Saturday	Closed
Sunday	Closed