Side by side. Every step of the way.

There are two ways to register:

  1. CLICK TO DOWNLOAD THIS FORM, complete it and bring it with you. 
  2. REGISTER ONLINE: Simply fill out the form below.

* = Required

Client Contact Information

First Name*: Last Name*:

Date of Birth:* Year:

Home Address*:

City*: State*: Zip*:

County*:

Primary Phone*: Type:
Secondary Phone: Type:

Email Address:

Name of Parent or Guardian if client is under 18:

Cancer Diagnosis*:

Date of Diagnosis: Year:


If this information was completed by someone other than the client:

Your Name:

Relationship to Client:

Phone: Type:

Is the client aware that Cancer Services will be contacting them? Yes No

In submitting this information, I understand that Cancer Services of Northeast Indiana will not release names, addresses, or mailing lists to others without my consent and will use the above information to offer and/or provide services related to the cancer diagnosis to the client and his/her family.

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Our Client Advocates:
  • Assess and identify the full range of family needs
  • Work with clients on an ongoing basis to assure needs are met
  • Provide supportive counsel to clients and families
  • Enhance quality of life by providing meaningful resources, information and compassionate assistance