{"id":7,"date":"2024-10-04T09:45:01","date_gmt":"2024-10-04T09:45:01","guid":{"rendered":"https:\/\/www.hemecancer.org\/registration\/?page_id=7"},"modified":"2025-05-27T04:13:46","modified_gmt":"2025-05-27T04:13:46","slug":"patient-support-group-registration-form","status":"publish","type":"page","link":"https:\/\/www.hemecancer.org\/registration\/patient-support-group-registration-form\/","title":{"rendered":"Patient Support Group Registration Form"},"content":{"rendered":"<p style=\"text-align: center; font-size: 35px; font-weight: 600; margin-bottom: 35px;\">Patient Support Group Registration Form<\/p>\n<div class='fluentform ff-default fluentform_wrapper_3 ffs_default_wrap'><form data-form_id=\"3\" id=\"fluentform_3\" class=\"frm-fluent-form fluent_form_3 ff-el-form-top ff_form_instance_3_1 ff-form-loading ffs_default\" data-form_instance=\"ff_form_instance_3_1\" method=\"POST\" ><fieldset  style=\"border: none!important;margin: 0!important;padding: 0!important;background-color: transparent!important;box-shadow: none!important;outline: none!important; min-inline-size: 100%;\">\n                    <legend class=\"ff_screen_reader_title\" style=\"display: block; margin: 0!important;padding: 0!important;height: 0!important;text-indent: -999999px;width: 0!important;overflow:hidden;\">Patient Support Group Registration Form<\/legend><input type='hidden' name='__fluent_form_embded_post_id' value='7' \/><input type=\"hidden\" id=\"_fluentform_3_fluentformnonce\" name=\"_fluentform_3_fluentformnonce\" value=\"0ed9af2f42\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/registration\/wp-json\/wp\/v2\/pages\/7\" \/><div data-type=\"name-element\" data-name=\"names\" class=\" ff-field_container ff-name-field-wrapper\" ><div class='ff-t-container'><div class='ff-t-cell '><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_names_first_name_' >Full Name<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"names[first_name]\" id=\"ff_3_names_first_name_\" class=\"ff-el-form-control\" aria-invalid=\"false\" aria-required=true><\/div><\/div><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_email' aria-label=\"Email Address\">Email Address<\/label><\/div><div class='ff-el-input--content'><input type=\"email\" name=\"email\" id=\"ff_3_email\" class=\"ff-el-form-control\" data-name=\"email\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_numeric_field' aria-label=\"Phone Number\">Phone Number<\/label><\/div><div class='ff-el-input--content'><input type=\"number\" name=\"numeric_field\" id=\"ff_3_numeric_field\" class=\"ff-el-form-control\" data-name=\"numeric_field\" inputmode=\"numeric\" step=\"any\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group ff-el-form-left'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text' aria-label=\"Current Address\">Current Address<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text\" class=\"ff-el-form-control\" data-name=\"input_text\" id=\"ff_3_input_text\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Category (Please Select One):\">Category (Please Select One):<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2f65366d78febb8639d1d47dc695c69f><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Patient\"  id='input_radio_2f65366d78febb8639d1d47dc695c69f' aria-label='Patient' aria-invalid='false' aria-required=true> <span>Patient<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7a92279154a0cc890432e7eee43346f0><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Caregiver\"  id='input_radio_7a92279154a0cc890432e7eee43346f0' aria-label='Caregiver' aria-invalid='false' aria-required=true> <span>Caregiver<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_91d3976c95b7d5140c183a05335311b1><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Survivor\"  id='input_radio_91d3976c95b7d5140c183a05335311b1' aria-label='Survivor' aria-invalid='false' aria-required=true> <span>Survivor<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_a995136c10bac43b0030a2d67768854e><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Volunteer\"  id='input_radio_a995136c10bac43b0030a2d67768854e' aria-label='Volunteer' aria-invalid='false' aria-required=true> <span>Volunteer<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_085b59bc5b6c3a12bbb2b8d4c1902e58><input  type=\"radio\" name=\"input_radio\" data-name=\"input_radio\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other: (Please specify) \"  id='input_radio_085b59bc5b6c3a12bbb2b8d4c1902e58' aria-label='Other: (Please specify)' aria-invalid='false' aria-required=true> <span>Other: (Please specify) <\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_1' aria-label=\"Other: Category\">Other: Category<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_1\" class=\"ff-el-form-control\" data-name=\"input_text_1\" id=\"ff_3_input_text_1\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Areas of Interest (Please select all that apply):\">Areas of Interest (Please select all that apply):<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_db9ce3523f454729b58743b1c126b1dc><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Hematologic malignancy treatments \"  id='checkbox_db9ce3523f454729b58743b1c126b1dc' aria-label='Hematologic malignancy treatments' aria-invalid='false' aria-required=true> <span>Hematologic malignancy treatments <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4add823147a13c3dffa1998a940bfb4f><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Nutrition during and after cancer treatment\"  id='checkbox_4add823147a13c3dffa1998a940bfb4f' aria-label='Nutrition during and after cancer treatment' aria-invalid='false' aria-required=true> <span>Nutrition during and after cancer treatment<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_4c8dd21f35792c0ada2d395a62f3e8bd><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Mental wellbeing of patients and caregivers during and after treatment\"  id='checkbox_4c8dd21f35792c0ada2d395a62f3e8bd' aria-label='Mental wellbeing of patients and caregivers during and after treatment' aria-invalid='false' aria-required=true> <span>Mental wellbeing of patients and caregivers during and after treatment<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_435201e0d10ec9df4368eb617b47fd99><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Physical rehabilitation post-treatment \"  id='checkbox_435201e0d10ec9df4368eb617b47fd99' aria-label='Physical rehabilitation post-treatment' aria-invalid='false' aria-required=true> <span>Physical rehabilitation post-treatment <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_9927362564ed161f8f2396594acc5566><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Financial support and resources for treatment\"  id='checkbox_9927362564ed161f8f2396594acc5566' aria-label='Financial support and resources for treatment' aria-invalid='false' aria-required=true> <span>Financial support and resources for treatment<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_bb2b7379a5b5f79b89b7f18c3b05a4ee><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Emotional support and counselling\"  id='checkbox_bb2b7379a5b5f79b89b7f18c3b05a4ee' aria-label='Emotional support and counselling' aria-invalid='false' aria-required=true> <span>Emotional support and counselling<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_0bf8b2639b96c7d71f5d7b918769cd25><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"New treatments and research updates\"  id='checkbox_0bf8b2639b96c7d71f5d7b918769cd25' aria-label='New treatments and research updates' aria-invalid='false' aria-required=true> <span>New treatments and research updates<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_16ee2db2291977fb71ecee2352e92ba6><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Long term side effects of cancer treatment\"  id='checkbox_16ee2db2291977fb71ecee2352e92ba6' aria-label='Long term side effects of cancer treatment' aria-invalid='false' aria-required=true> <span>Long term side effects of cancer treatment<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_bd5f8a14dee56ac78d94f324f7df3db7><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Life expectancy in blood cancers\"  id='checkbox_bd5f8a14dee56ac78d94f324f7df3db7' aria-label='Life expectancy in blood cancers' aria-invalid='false' aria-required=true> <span>Life expectancy in blood cancers<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_93c10abfc65149fc78c1624db0b9c899><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Life style modifications during and after cancer treatments\"  id='checkbox_93c10abfc65149fc78c1624db0b9c899' aria-label='Life style modifications during and after cancer treatments' aria-invalid='false' aria-required=true> <span>Life style modifications during and after cancer treatments<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=checkbox_d34de8e06f57c4835636f4099055cab7><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other\"  id='checkbox_d34de8e06f57c4835636f4099055cab7' aria-label='Other' aria-invalid='false' aria-required=true> <span>Other<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_2' aria-label=\"Other Areas of Interest\">Other Areas of Interest <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_2\" class=\"ff-el-form-control\" data-name=\"input_text_2\" id=\"ff_3_input_text_2\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_1\" ><p style=\"margin: 0px;font-weight: 600;color: #dc651e\">Support Group Preferences:<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"How frequently would you like to participate in support group meetings?\">How frequently would you like to participate in support group meetings?  <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_1_a8f8d357341cbce520add8d7cebff7b6><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Weekly\"  id='input_radio_1_a8f8d357341cbce520add8d7cebff7b6' aria-label='Weekly' aria-invalid='false' aria-required=true> <span>Weekly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_1_f5b012a543371da4b51b22e1f24b3064><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Bi-weekly \"  id='input_radio_1_f5b012a543371da4b51b22e1f24b3064' aria-label='Bi-weekly' aria-invalid='false' aria-required=true> <span>Bi-weekly <\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_1_7edac353e97094e931c7c83a91f06d19><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Monthly\"  id='input_radio_1_7edac353e97094e931c7c83a91f06d19' aria-label='Monthly' aria-invalid='false' aria-required=true> <span>Monthly<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_1_f0057ae8022a303185bb1437463cb756><input  type=\"radio\" name=\"input_radio_1\" data-name=\"input_radio_1\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"As needed\"  id='input_radio_1_f0057ae8022a303185bb1437463cb756' aria-label='As needed' aria-invalid='false' aria-required=true> <span>As needed<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"What format would you prefer for support group sessions?\">What format would you prefer for support group sessions?<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_79222cfa5a78141e601743a96a543731><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"In-person\"  id='input_radio_2_79222cfa5a78141e601743a96a543731' aria-label='In-person' aria-invalid='false' aria-required=true> <span>In-person<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_7d0597bdd620a3eaf984824fa5cfcef6><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Online\"  id='input_radio_2_7d0597bdd620a3eaf984824fa5cfcef6' aria-label='Online' aria-invalid='false' aria-required=true> <span>Online<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_2_4dec65736ce5d81ede5642d81c214ac2><input  type=\"radio\" name=\"input_radio_2\" data-name=\"input_radio_2\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Hybrid (in-person and online)\"  id='input_radio_2_4dec65736ce5d81ede5642d81c214ac2' aria-label='Hybrid (in-person and online)' aria-invalid='false' aria-required=true> <span>Hybrid (in-person and online)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Would you be open to one-on-one peer support?\">Would you be open to one-on-one peer support? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_42c7f2d0c48bd242ba0bad931ee8d9ec><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_3_42c7f2d0c48bd242ba0bad931ee8d9ec' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_3_22d681da58e73481cbdb9311f7373ee9><input  type=\"radio\" name=\"input_radio_3\" data-name=\"input_radio_3\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_3_22d681da58e73481cbdb9311f7373ee9' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html' tabindex='-1' data-name=\"custom_html-3_2\" ><p style=\"margin: 0px;font-weight: 600;color: #dc651e\">Newsletter Subscription:<\/p><\/div><div class='ff-el-group'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Would you like to receive mailers on the above topics?\">Would you like to receive mailers on the above topics? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_650b77199c72e0bbc4ce3bdcf10ed06a><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_4_650b77199c72e0bbc4ce3bdcf10ed06a' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_4_0b50328d111b6324145697a0b337bc66><input  type=\"radio\" name=\"input_radio_4\" data-name=\"input_radio_4\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_4_0b50328d111b6324145697a0b337bc66' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_3\" ><p style=\"margin: 0px;font-weight: 600;color: #dc651e\">Medical Information (for patients only):<\/p><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_3' aria-label=\"Type of Cancer:\">Type of Cancer:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_3\" class=\"ff-el-form-control\" data-name=\"input_text_3\" id=\"ff_3_input_text_3\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_4' aria-label=\"Date of Diagnosis:\">Date of Diagnosis:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_4\" class=\"ff-el-form-control\" data-name=\"input_text_4\" id=\"ff_3_input_text_4\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_5' aria-label=\"Treatment Received (Chemotherapy, Radiation, etc.):\">Treatment Received (Chemotherapy, Radiation, etc.):<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_5\" class=\"ff-el-form-control\" data-name=\"input_text_5\" id=\"ff_3_input_text_5\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Are you currently undergoing treatment?\">Are you currently undergoing treatment? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_4322f98b51f372859a8b2d30aa2f0303><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"yes\"  id='input_radio_5_4322f98b51f372859a8b2d30aa2f0303' aria-label='Yes' aria-invalid='false' aria-required=true> <span>Yes<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_5_3fcea8f8b32fd2ffae83e913bbb7e36a><input  type=\"radio\" name=\"input_radio_5\" data-name=\"input_radio_5\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"no\"  id='input_radio_5_3fcea8f8b32fd2ffae83e913bbb7e36a' aria-label='No' aria-invalid='false' aria-required=true> <span>No<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_6' aria-label=\"Name of the Hospital where treatment received\">Name of the Hospital where treatment received<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_6\" class=\"ff-el-form-control\" data-name=\"input_text_6\" id=\"ff_3_input_text_6\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_4\" ><p style=\"margin: 0px;font-weight: 600;color: #dc651e\">If You Are a Survivor:<\/p><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_7' aria-label=\"Year of Treatment Completion:\">Year of Treatment Completion: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_7\" class=\"ff-el-form-control\" data-name=\"input_text_7\" id=\"ff_3_input_text_7\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_8' aria-label=\"Type of Cancer Treated:\">Type of Cancer Treated: <\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_8\" class=\"ff-el-form-control\" data-name=\"input_text_8\" id=\"ff_3_input_text_8\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"Current Occupation:\">Current Occupation:<\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_ed7cf2130dcecb77bc96b1cab4d1090f><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Studying\"  id='input_radio_6_ed7cf2130dcecb77bc96b1cab4d1090f' aria-label='Studying' aria-invalid='false' aria-required=true> <span>Studying<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_1850124968fb17ea10799db1cf5defc2><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Employed\"  id='input_radio_6_1850124968fb17ea10799db1cf5defc2' aria-label='Employed' aria-invalid='false' aria-required=true> <span>Employed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_63cee4820d2dd07a06ac933771c72c75><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Self-employed\"  id='input_radio_6_63cee4820d2dd07a06ac933771c72c75' aria-label='Self-employed' aria-invalid='false' aria-required=true> <span>Self-employed<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_7a0c340b2cc405917a20ebe19027f668><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Homemaker\"  id='input_radio_6_7a0c340b2cc405917a20ebe19027f668' aria-label='Homemaker' aria-invalid='false' aria-required=true> <span>Homemaker<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_6_82c88ae357ba1a03cea0a60a0dca9c1f><input  type=\"radio\" name=\"input_radio_6\" data-name=\"input_radio_6\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other: (Please specify)\"  id='input_radio_6_82c88ae357ba1a03cea0a60a0dca9c1f' aria-label='Other: (Please specify)' aria-invalid='false' aria-required=true> <span>Other: (Please specify)<\/span><\/label><\/div><\/div><\/div><div class='ff-el-group ff-el-form-left has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_9' aria-label=\"Other Occupation:\">Other Occupation:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_9\" class=\"ff-el-form-control\" data-name=\"input_text_9\" id=\"ff_3_input_text_9\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group  ff-custom_html has-conditions' tabindex='-1' data-name=\"custom_html-3_5\" ><p style=\"margin: 0px;font-weight: 600;color: #dc651e\">Caregiver Information (for caregivers only):<\/p><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_10' aria-label=\"Relation to the Patient:\">Relation to the Patient:<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_10\" class=\"ff-el-form-control\" data-name=\"input_text_10\" id=\"ff_3_input_text_10\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label asterisk-right\"><label for='ff_3_input_text_11' aria-label=\"Patient\u2019s Current Condition (if applicable):\">Patient\u2019s Current Condition (if applicable):<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_11\" class=\"ff-el-form-control\" data-name=\"input_text_11\" id=\"ff_3_input_text_11\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label for='ff_3_input_text_12' aria-label=\"How long have you been a caregiver?\">How long have you been a caregiver?<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_12\" class=\"ff-el-form-control\" data-name=\"input_text_12\" id=\"ff_3_input_text_12\"  aria-invalid=\"false\" aria-required=true><\/div><\/div><div class='ff-el-group has-conditions'><div class=\"ff-el-input--label ff-el-is-required asterisk-right\"><label  aria-label=\"What support would you find helpful as a caregiver?\">What support would you find helpful as a caregiver? <\/label><\/div><div class='ff-el-input--content'><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_37c3c2ce2e5d5ea0a7bcb043687401bc><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Emotional support\"  id='input_radio_7_37c3c2ce2e5d5ea0a7bcb043687401bc' aria-label='Emotional support' aria-invalid='false' aria-required=true> <span>Emotional support<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_b340dddd1151b2a9972917e19cc8b45f><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Training in patient care\"  id='input_radio_7_b340dddd1151b2a9972917e19cc8b45f' aria-label='Training in patient care' aria-invalid='false' aria-required=true> <span>Training in patient care<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_5c4b96597dea7f15faacf232339ddf4e><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Financial guidance\"  id='input_radio_7_5c4b96597dea7f15faacf232339ddf4e' aria-label='Financial guidance' aria-invalid='false' aria-required=true> <span>Financial guidance<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' 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