{"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=\"4e42397181\" \/><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_1c490189daef6e293864a2032554f5a3><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_1c490189daef6e293864a2032554f5a3' 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_bd3fb2d58970e69bee360e7ed473524e><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_bd3fb2d58970e69bee360e7ed473524e' 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_cd2e256ac256a2adc7c14a6852748220><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_cd2e256ac256a2adc7c14a6852748220' 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_eb62af8c8c7d5183dd886f987973b8c8><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_eb62af8c8c7d5183dd886f987973b8c8' 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_d7d418223d6efa0dc784f3f9de8bccfa><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_d7d418223d6efa0dc784f3f9de8bccfa' 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_353b29a65534f36e77c8d6b593bc5c87><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_353b29a65534f36e77c8d6b593bc5c87' 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_bb5d164471c79ce9a3001a35a77d4d2b><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_bb5d164471c79ce9a3001a35a77d4d2b' 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_b1a5c4ff2b78afeee681b2a6f7707a10><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_b1a5c4ff2b78afeee681b2a6f7707a10' 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_accfa5ab01aa68a097ad7b1017b95a8c><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_accfa5ab01aa68a097ad7b1017b95a8c' 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_9aeb5ca1319dda2a48b2c0ef38bd605e><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_9aeb5ca1319dda2a48b2c0ef38bd605e' 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_6cbd155ee0170063bb81f4d270a98a4c><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_6cbd155ee0170063bb81f4d270a98a4c' 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_8abab5cdb8c51613c3fc439d3f6f14dc><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_8abab5cdb8c51613c3fc439d3f6f14dc' 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_c11d09af9c14addae9682d000b0fdb24><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_c11d09af9c14addae9682d000b0fdb24' 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_523a15ba07de033d366494ea438315da><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_523a15ba07de033d366494ea438315da' 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_e27ebaa1b4f72dd37dd52f588c3d623e><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_e27ebaa1b4f72dd37dd52f588c3d623e' 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_b156b3259bc10b03ac9f193ace9f5cdb><input  type=\"checkbox\" name=\"checkbox[]\" data-name=\"checkbox\" class=\"ff-el-form-check-input ff-el-form-check-checkbox\" value=\"Other\"  id='checkbox_b156b3259bc10b03ac9f193ace9f5cdb' 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_026da30379729835354a4d234ccef7bc><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_026da30379729835354a4d234ccef7bc' 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_7eaf99fa276b4e41a780d7e5a6df79e3><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_7eaf99fa276b4e41a780d7e5a6df79e3' 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_77053c5e356772a1be3ad46b3476763e><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_77053c5e356772a1be3ad46b3476763e' 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_2719d4236fa0572ef27023278b7362c0><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_2719d4236fa0572ef27023278b7362c0' 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_c6a2a57dd61c1ab0d413a7716084cf3b><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_c6a2a57dd61c1ab0d413a7716084cf3b' 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_f2f3cc6bda5bdd46d6caad96b54752d4><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_f2f3cc6bda5bdd46d6caad96b54752d4' 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_b91bf68fbd0c994beff1cd8ac188dc54><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_b91bf68fbd0c994beff1cd8ac188dc54' 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_572aa4d32cf63cead68a201f7c30f80c><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_572aa4d32cf63cead68a201f7c30f80c' 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_1889fbbceb5fc273369cd8ed5bc1fe2a><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_1889fbbceb5fc273369cd8ed5bc1fe2a' 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_84df1a5e902616897ab639e7c99237e3><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_84df1a5e902616897ab639e7c99237e3' 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_3a2b9411e51dfd6911e93ab4a62d138c><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_3a2b9411e51dfd6911e93ab4a62d138c' 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_cc8fe05636e2c5ac3d21007055092540><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_cc8fe05636e2c5ac3d21007055092540' 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_5ef56ea76549d7b950ff1b566b465b46><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_5ef56ea76549d7b950ff1b566b465b46' 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_34f062965b9fdef1dc0f1fd66b813674><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_34f062965b9fdef1dc0f1fd66b813674' 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_82a7297c56a09e09548516f1143e454a><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_82a7297c56a09e09548516f1143e454a' 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_ce35d5da4bc2139ec7e93f352e510fad><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_ce35d5da4bc2139ec7e93f352e510fad' 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_414c07da5dcc436809030f738feb423a><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_414c07da5dcc436809030f738feb423a' 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_442654c4ecd01d83f5df22797a1e8f8f><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_442654c4ecd01d83f5df22797a1e8f8f' 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_d0a655985d8ce2b561b82b5f95205c15><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_d0a655985d8ce2b561b82b5f95205c15' 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_c634d452cbf608db2db4fb96e970cfa0><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_c634d452cbf608db2db4fb96e970cfa0' 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_430d6fb3b0a0d22c5a02d4caf6886d02><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_430d6fb3b0a0d22c5a02d4caf6886d02' 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' for=input_radio_7_43172803cc8bc95962f740dc364d347e><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Respite services\"  id='input_radio_7_43172803cc8bc95962f740dc364d347e' aria-label='Respite services' aria-invalid='false' aria-required=true> <span>Respite services<\/span><\/label><\/div><div class='ff-el-form-check ff-el-form-check-'><label class='ff-el-form-check-label' for=input_radio_7_0d57570f1914935fd6fbb0954381cb82><input  type=\"radio\" name=\"input_radio_7\" data-name=\"input_radio_7\" class=\"ff-el-form-check-input ff-el-form-check-radio\" value=\"Other\"  id='input_radio_7_0d57570f1914935fd6fbb0954381cb82' aria-label='Other' aria-invalid='false' aria-required=true> <span>Other<\/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_13' aria-label=\"Other Support\">Other Support<\/label><\/div><div class='ff-el-input--content'><input type=\"text\" name=\"input_text_13\" class=\"ff-el-form-control\" data-name=\"input_text_13\" id=\"ff_3_input_text_13\"  aria-invalid=\"false\" aria-required=false><\/div><\/div><div class='ff-el-group ff-text-left ff_submit_btn_wrapper'><button type=\"submit\" class=\"ff-btn ff-btn-submit ff-btn-md ff_btn_style\" >Submit Form<\/button><\/div><\/fieldset><\/form><div id='fluentform_3_errors' class='ff-errors-in-stack ff_form_instance_3_1 ff-form-loading_errors ff_form_instance_3_1_errors'><\/div><\/div>        <script type=\"text\/javascript\">\n            window.fluent_form_ff_form_instance_3_1 = {\"id\":\"3\",\"settings\":{\"layout\":{\"labelPlacement\":\"top\",\"helpMessagePlacement\":\"with_label\",\"errorMessagePlacement\":\"inline\",\"cssClassName\":\"\",\"asteriskPlacement\":\"asterisk-right\"},\"restrictions\":{\"denyEmptySubmission\":{\"enabled\":false}}},\"form_instance\":\"ff_form_instance_3_1\",\"form_id_selector\":\"fluentform_3\",\"rules\":{\"names[first_name]\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[middle_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"names[last_name]\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"email\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"email\":{\"value\":true,\"message\":\"This field must contain a valid email\",\"global_message\":\"This field must contain a valid email\",\"global\":true}},\"numeric_field\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true},\"numeric\":{\"value\":true,\"message\":\"This field must contain numeric value\",\"global_message\":\"This field must contain numeric value\",\"global\":true},\"min\":{\"value\":\"\",\"message\":\"Validation fails for minimum value\",\"global_message\":\"Validation fails for minimum value\",\"global\":true},\"max\":{\"value\":\"\",\"message\":\"Validation fails for maximum value\",\"global_message\":\"Validation fails for maximum value\",\"global\":true},\"digits\":{\"value\":\"\",\"message\":\"Validation fails for limited digits\",\"global_message\":\"Validation fails for limited digits\",\"global\":true}},\"input_text\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_1\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"checkbox\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_2\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_1\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_2\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_4\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_3\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_4\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_5\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_7\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_8\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_6\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_9\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_10\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_11\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_12\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_radio_7\":{\"required\":{\"value\":true,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}},\"input_text_13\":{\"required\":{\"value\":false,\"message\":\"This field is required\",\"global_message\":\"This field is required\",\"global\":true}}},\"debounce_time\":300,\"conditionals\":{\"input_text_1\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Other: (Please specify) \",\"operator\":\"=\"}]},\"input_text_2\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"checkbox\",\"value\":\"Other\",\"operator\":\"=\"}]},\"custom_html-3_3\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Patient\",\"operator\":\"=\"}]},\"input_text_3\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Patient\",\"operator\":\"=\"}]},\"input_text_4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Patient\",\"operator\":\"=\"}]},\"input_text_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Patient\",\"operator\":\"=\"}]},\"input_radio_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Patient\",\"operator\":\"=\"}]},\"input_text_6\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Patient\",\"operator\":\"=\"}]},\"custom_html-3_4\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Survivor\",\"operator\":\"=\"}]},\"input_text_7\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Survivor\",\"operator\":\"=\"}]},\"input_text_8\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Survivor\",\"operator\":\"=\"}]},\"input_radio_6\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Survivor\",\"operator\":\"=\"}]},\"input_text_9\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_6\",\"value\":\"Other: (Please specify)\",\"operator\":\"=\"}]},\"custom_html-3_5\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Caregiver\",\"operator\":\"=\"}]},\"input_text_10\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Caregiver\",\"operator\":\"=\"}]},\"input_text_11\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Caregiver\",\"operator\":\"=\"}]},\"input_text_12\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Caregiver\",\"operator\":\"=\"}]},\"input_radio_7\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio\",\"value\":\"Caregiver\",\"operator\":\"=\"}]},\"input_text_13\":{\"type\":\"any\",\"status\":true,\"conditions\":[{\"field\":\"input_radio_7\",\"value\":\"Other\",\"operator\":\"=\"}]}}};\n                    <\/script>\n        \n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-7","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/pages\/7","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/comments?post=7"}],"version-history":[{"count":5,"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/pages\/7\/revisions"}],"predecessor-version":[{"id":70,"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/pages\/7\/revisions\/70"}],"wp:attachment":[{"href":"https:\/\/www.hemecancer.org\/registration\/wp-json\/wp\/v2\/media?parent=7"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}