Request a Coach

Complete this application if you are interested in being matched with a Cancer Coach. Your application will reviewed and you will be contacted by our Cancer Coach Coordinator to further discuss your needs and the next steps in being matched with a Cancer Coach.

Fields marked with an asterisk * are required.

Personal Information

About You

Your The patient's biologically assigned gender *

Contact Methods

Residential Address

Treatment Information

Answering these questions will enable us to place you most effectively with a coach that has had similar experiences to yours.

Stage/grade of cancer *
What types of treatment have you  has the patient received as part of your  their care? *

Additional Information

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

By checking this box to apply to be a participant 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 coach and partners of the program to support your needs. *