Cancer Survivor Registration & Story Submission

You Are Already Registered

You have already completed your survivor profile. Log in to your portal to manage your stories and updates.

1. Personal & Contact Information

Full Legal Name *

Date of Birth *

Gender Male Female Other

Email Address *

Mobile / Phone Number *

City

State / Country

2. Medical Diagnosis & Treatment History

Type of Cancer *

Stage at Diagnosis

Year of Diagnosis

Treating Hospital / Primary Oncologist

Treatments Received

Surgery Chemotherapy Radiation Immunotherapy Targeted Therapy Other

Current Health Status In Remission / Cancer-Free
Currently in Active Treatment
Maintenance / Targeted Therapy
Living with Metastatic Cancer
Other Status

If Other Status, Describe

3. Survivor Portal Login Setup

Choose Username (Optional)

Password

Confirm Password

4. Communication Preferences & Publication Consents

Preferred Contact Methods

Phone Call Email WhatsApp / SMS

Best Time to Reach You

Story Sharing Consents

Consent to display on ONCORG Website Consent to share inspiring excerpts on Social Media Consent for educational publications Interested in participating in a video / podcast interview Connect with other survivor members in the Community

I confirm that the information provided above is accurate to the best of my knowledge. I grant permission to ONCORG to register my survivor profile and contact me regarding my story participation. *

Digital Signature (Type Full Legal Name) *

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