First Time Visitors Form

All of Our Programs Are Currently Virtual Due to COVID-19.

Your data is kept confidential at Hope Connections. Your information will never be sold or shared with a third party.
Email*
Today's Date*
MM slash DD slash YYYY
Personal & Contact Information
Name*
First Last
Date of Birth*
Month
Day
Year
Gender*
- Woman
- Man
- Transgender
- Non-binary/non-conforming
- Prefer not to respond
Address*
Street Address City State ZIP Code
Primary contact number*
Primary contact number type*
Additional contact number
Additional contact number type
I am:*
About
Please complete the following for yourself or for the person you are here to support.
Cancer Diagnosis-Click to select*
Name Of Patient If Not Self
First Last
Date diagnosed*
MM slash DD slash YYYY
Oncologist's name
First Last
Hospital (name and location)
Emergency contact name*
First Last
Cell Phone Number*
Relationship
The next two questions are optional. This information will be kept confidential and not shared with your employer and will be aggregated for grant purposes only.
Employer (Optional)
Household Income (Optional)
Special resources are available for those with household incomes below $25K
Additional Information
Please note: Attendance at an orientation is required before attending Support Groups and Mind/Body classes. Unless otherwise noted, all of our programming are for those age 18 and over. Comfortable clothing and physician approval recommended for all exercise Mind/Body Classes.
Which of our programs are you interested in attending? Choose all that apply:*
- Support Groups
- Mind/Body Classes
- Educational Programs
- Social Events
- Volunteer Opportunities
How did you hear about us? Check all that apply:*
- Doctor
- Nurse
- Social Worker
- Maryland Oncology and Hematology
- Family
- Friend
- Employer
- Newspaper/Magazine
- Radio
- Internet
- Hope Connections Staff/Volunteer
- Hope Connections Care Bags
- Other
Referral Name*

Please write the name of the person who referred you, or n/a if not applicable.
Would you like to receive our quarterly program calendar and information on upcoming programs and special events via email?*
- Yes
- No
Hope Connections reserves the right to refuse to provide services to participants and to allow participants to engage in Hope Connections programs who violate or threaten to violate Hope Connections’ policies, are threatening or disruptive to staff or other participants or who appear to present a potential danger to the participant, staff or other participants.
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Our Programs are Free. Your Donations Make this Happen!

Become part of our community, whether or not you have cancer. Learn how you can help Hope Connections ensure that those with cancer get the support, caring, and compassion they need.

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First Time Visitors Form

First Time Visitors Form

Personal & Contact Information

About

Additional Information

Our Programs are Free. Your Donations Make this Happen!