GWCCS Membership Application

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Please PRINT and mail this to:

GWCCS Membership
4848 Albemarle Street, NW
Washington DC 20016-4347		 I am including a check payable to "GWCCS" in the amount of:

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Application Date: ____________

Name: __________________________________

Address: ___________________________________________

___________________________________________________

City: ______________________ State: ___ ZIP:________

Phone (H): ____ - ____ - ______ (O): ____ - ____ - ______

E-mail address: ____________________ Fax:: ____ - ____ - ______

Cancer Survivor:

Date of Diagnosis: ______________

Diagnosis: ________________________________________________________

As a survivor, I am willing to share my experiences and encouraging phone calls with others with a similar diagnosis.
Yes ___ No ___

Caregiver:

Please provide survivor’s Name: __________________________

Survivor’s Date of Diagnosis: __________________

Diagnosis: ________________________________________________________

As a caregiver, I am willing to share my experiences and encouraging phone calls with others with a similar diagnosis.   
Yes ___ No ___

Professional:

Physician__ Nurse__ Social Worker__ Other__

Institution Name: _______________________________________________

Address: ___________________________________________

___________________________________________________

City: ______________________ State: ___ ZIP:________

Phone (H): ____ - ____ - ______ (O): ____ - ____ - ______

E-mail address: _________________

Web site URL: _____________________ 

Institutional - Fax #: _____ - ____ - ________

Save a copy of this for your taxes, GWCCS is a 501(c)(3) tax-exempt organization.

Administrator