Community Collaboration Program Registration Form First Name(Required) Last Name(Required) Phone(Required)Email(Required) Please tell us about your connection with childhood and adolescent cancer.I am a … Parent or carer of a child or adolescent affected by cancer Young adult who had cancer as a child or young adult (must be 18+ years old) Other What stage of treatment is your child in? Active Treatment Maintenance Treatment Completed treatment less than two years ago Completed treatment more than two years ago Bereaved Other What stage of treatment are you in? Active Treatment Maintenance Treatment Completed treatment less than two years ago Completed treatment more than two years ago Other Your Child's Diagnosis(Required) What was your diagnosis?(Required) Has your child ever been enrolled in a clinical trial during their treatment?(Required)YesNoUnsureHave you ever been enrolled in a clinical trial during your treatment?(Required)YesNoUnsureWhat is/was your child's main treatment hospital?(Required)The Royal Children's HospitalMonash Children's HospitalSydney Children's HospitalChildren's Hospital at WestmeadJohn Hunter Children's HospitalQueensland Children's HospitalWomen and Children's Hospital (Adelaide)Perth Children's HospitalRoyal Hobart HospitalStarship Children's HospitalChristchurch HospitalOtherWhat is/was your main treatment hospital?(Required)The Royal Children's HospitalMonash Children's HospitalSydney Children's HospitalChildren's Hospital at WestmeadJohn Hunter Children's HospitalQueensland Children's HospitalWomen and Children's Hospital (Adelaide)Perth Children's HospitalRoyal Hobart HospitalStarship Children's HospitalChristchurch HospitalOtherIf other, please let us know which hospital. To ensure diverse input across the Community Collaboration Program, please let us know a bit more information about yourself/your family.What state or territory do you live?(Required)VictoriaNew South WalesQueenslandSouth AustraliaWest AustraliaNorthern TerritoryAustralian Capital TerritoryTasmaniaNew ZealandOtherDo you speak a language other than English?(Required)NoYesWhat language do you speak?(Required) Do you require information to be translated to aid in your participation in this program?(Required)YesNoAre you of Aboriginal or Torres Strait Islander origin?(Required)NoYes, AboriginalYes, Torres Strait IslanderYes, both Aboriginal and Torres Strait IslanderHow did you hear about the ANZCHOG Community Collaboration Program?(Required) Social Media Web Search Flyer in hospital Doctor or other healthcare provider From another family Through a charity Other Are you interested in joining the ANZCHOG Community Collaboration Group (CCG) in addition to participating in the registry?NoYes
