Cancer Survivor Registration

1

Personal Information

Full Name *

Date of Birth *

Gender *

Male Female Prefer not to say Other

Mobile Number *

Email Address *

City

State / Country

2

Cancer Journey Information

Type of Cancer *

Stage at Diagnosis

Year of Diagnosis

Hospital / Treating Doctor (Optional)

Treatment Received (Select all that apply)

Surgery Chemotherapy Radiation Therapy Immunotherapy Targeted Therapy Other:

Current Status *

Survivor (Completed Treatment) Under Treatment Remission

Other:

3

Story Participation Consent

I am willing to share my cancer journey story with ONCORG for:

Website Publication Social Media Awareness Educational Programs Video Interview Community Support Programs

4

Account Creation (For Portal Access)

Create your login credentials to access the Survivor Portal. If you leave password blank, ONCORG will generate credentials for you.

Preferred Username

Password *

Min 6 characters

Confirm Password *

5

Communication Preferences

Preferred Contact Method

Phone Email WhatsApp

Best Time to Call

6

Consent & Declaration

All information is kept strictly confidential. ONCORG will not share your story or contact you without your explicit permission.

I confirm that the information provided above is true to the best of my knowledge. I give permission to ONCORG to create a user account and contact me regarding my survivor story participation.

Signature (Type Full Name) *

Date

Already have an account?

If you have already registered with ONCORG as a Cancer Survivor, log in to access your Survivor Portal and manage your story.

ONCORG | Supporting Cancer Patients & Survivors | www.oncorg.com

Cancer Survivor Story Registration