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DayTreat Registration Form

Name

First Name

Last Name

Date of Birth

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone Number

(###)

###

####

Emergency Contact and Phone Number

Name of Oncologist/Primary Physician

What would you like to gain from this DayTreat?

TYPE OF CANCER: Date of Diagnosis, Current Stage:

TREATMENTS

Are you currently in treatment, what kind and how long? Or, do you have an upcoming treatment(s), surgeries, and if so, when? Help Needed?

POST TREATMENT

If you have completed treatment, please highlight what you underwent and when you completed treatment? Help Needed?

HEALTH CONDITION

Tell us about your health condition or challenges and do you have any specific limitations, symptoms, or problems we can help you address?

The information provided is true to the best of my knowledge. I release and indemnify Maui Cancer Wellness Retreats of any liabilities.

I also authorize Maui Cancer Wellness Retreats the use of any photography or video's taken of me during the event. I also consent to have my email address added to the Maui Cancer Resources Email List.

For more information, please visit www.mauicancerresources.org