prepare to live : share your story

CLICK HERE TO READ PATIENT PROFILES: Or Share Your Story by Filling in the Form Below: Please take a moment to fill in this form for the benifit of others. The information and experiences you share here will provide fellow patients, survivors and caregivers with insights that can change and even save lives. Thanks for contributing to this invaluable resource and being a part of the Prepare to Live community. *Fields marked with an asterisk are required.
*First Name:		Last Name:
Patient	Survivor	Caregiver

Date diagnosed:		Date of Birth:
Male Female
Please answer the following 12 Patient Profile questions:
01: How has cancer positively affected you?
02: What does "cancer" mean to you as a Young Adult?
03: What’s the one thing you’d say to someone who has just been diagnosed?
04: What things won’t a Doctor tell you?
05: What advice do you have for caregivers of Young Adults with cancer?
06: Finish this sentence: Cancer is…
07: What is the best kind of support to give/receive?
08: Who or what were your best resources for information?
09: What has helped you the most?
10: What’s your favorite tip or trick for dealing?
11: The thing that keeps you going is…
12: What are you doing to Prepare To Live?
What additional comments, experiences or ideas would you like to share?
Would you be interested in any of the following:
Being notified about site updates, film releases and events? Yes No
Appearing in a film? Yes No
Being a Buddy? Yes No
Being contacted by Prepare to Live members? Yes No
Holding a fundraiser for Prepare to Live? Yes No
Donating skills to Prepare to Live? Yes No
If yes, what skills are you able to offer?
How did you hear about Prepare to Live?
Your contact details:
*Email:		Alternate Email:
Street Address:		Suburb:
State:	Post Code:	Country:
I am a member of Prepare to Live I would like to become a member of Prepare to Live I might join later
*I have read the Prepare to Live Privacy Policy and User Agreement

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