Become a Coach

Personal Information

About You

First name *

Last name *

Date of birth * (mm/dd/yyyy)

Your The patient's biologically assigned gender * Male Female

Contact Methods

Your Patient's Phone number * (###-###-####)

Your Patient's Email Address *

Residential Address

Street address *

City *

State/Province *

Zip code *

Treatment Information

Answering these questions about your treatment will enable us to place you most effectively with patients that are having similar experiences to yours.

Where did you receive treatment? *

Year of your diagnosis *

Year treatment was completed *

Have you had any recurrences? * Yes No

Year of recurrence *

Additional Information

Answering these questions about your volunteer experience and hobbies will enable us to place you most effectively with patients that are having similar experiences to yours.

Why do you want to become a Cancer Coach? *

If you knew what you know now, what advice would you give yourself as a newly diagnosed patient?

What would you like us to know about you?

Career, hobbies, children/grandchildren, family, pets, faith, etc.

Is there anything else you would like us to know while reviewing your application?

How did you hear about Roswell Park? *

Please explain *

By checking this box to apply to be a coach in the Roswell Park Comprehensive Cancer Center’s Cancer Coach program, you acknowledge giving authorization for the program administrators to share submitted information with your assigned coachee and partners of the program to support your needs. *

Yes, I agree

Your Patient's Residential Address