New Member/Annual Visitor Information Form

Each year, Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB) gathers information about every participant to help us better understand who comes to our programs. All personal information will be kept confidential. Since we are a non-profit organization that does not charge for our services, we rely solely on donations to underwrite our programs and we need to collect the following information annually to help us secure funding. The information provided to funders only includes demographic data of all participants with no identifying information. Your answers to these questions will, in no way, affect your ability to access all programs at CSCVVSB at no charge.

If you need help completing this form or have any questions, please contact us at programs@cancersupportvvsb.org.
Date*
Month
Day
Year
Name*
Prefix First Middle Last
Address*
Street Address City State ZIP Code
Home Phone
Cell Phone
Email
First time at CSCVVSB?*
I would like to receive the "Community Connect" email communication to stay informed about programs and events at CSCVVSB:
Would you like to receive Children/Teen/Family program information?*
Emergency Contact*
First Last
Emergency Contact Relationship*
Emergency Contact Phone*
Emergency Contact Phone Type*
How did you hear about CSCVVSB?*
Please specify:*
Please complete the following about YOURSELF
I am a*
Please specify other:*
If you are a support person, what is the relationship and name of the person with cancer you are here to support?*
Date of Birth*
Month
Day
Year
Please complete the following about yourself or for the person you are here to support
Type of Cancer*
Stage of Cancer
Date Diagnosed
Month
Day
Year
Oncologist's Name
Health Care Provider's name & location
City of Hope Location
St. John's Hospital/Dignity Health location
UCLA Health location
Please specify
I give you permission to let my oncologist know I am attending CSCVVSB programs*
The following information will ONLY be used for funding purposes and program assessment with NO identifying information.
Gender Identity*
Please specify other*
Sexual Orientation*
Please specify other*
Race/Ethnicity (check all that apply)*
- Asian/Pacific Islander
- Black/African American (non-Hispanic)
- Black-Hispanic
- American Indian/Alaska Native/First Nations
- White-Hispanic
- White (non-Hispanic)
- Other
Please specify other*
Insurance*
Employment Status*
Employer (or former employer if retired)
Annual Household Income*
Confidentiality & Member Safety Consent
Our staff and volunteers respect the privacy of our members. Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB) adheres to professional, legal, and ethical standards of confidentiality established by professional organizations and state law. Legal and ethical exceptions to confidentiality include: a clear or present danger to harm oneself or another, knowledge of the abuse or neglect of a minor child, elder or dependent/incapacitated adult, or responses to a court subpoena or as otherwise required by law.

We ask that our members respect each other’s privacy and do not disclose the identity of others who participate at CSCVVSB, or what is said in a support group or program. However, we are not able to ensure confidentiality of all members, as we would have no way to enforce it. Please read and sign below regarding our policies for the confidentiality, virtual (online) confidentiality and communication, comfort and safety of our members.
- I understand that the CSCVVSB staff and volunteers will be respectful of my privacy but cannot ensure the confidentiality adherence of other members.
- I understand that the CSCVVSB reserves the right, at its sole discretion, to refuse or discontinue the use of its facilities and its virtual (online) platforms to any person.
- I agree not to share other members’ personal information, such as name, address, email address, phone number, and medical information, to any other third party.
- I understand that the CSCVVSB does not provide medical advice or assistance of any kind.
- I agree not to attend the CSCVVSB programs if I have a communicable illness, as some of our members have compromised immune systems.
- I understand that the CSCVVSB is a fragrance-free space, as some members may be very sensitive to smell.
In consideration of my acceptance as a member of Cancer Support Community Valley/Ventura/Santa Barbara (CSCVVSB), and its partners (including, but not limited to: Saint John’s Dignity Health, Ventura County Medical Center) and the use of the facilities and services provided without charge, I agree that I will not take any legal action against the CSCVVSB, its program partners, its officers, agents, employees, interns, or any other participant or support person at CSCVVSB, based in any way on what is said or done by such officers, agents, employees and participants at CSCVVSB in a good faith effort to provide those services and facilities.

HEALTH LIFESTYLE/MIND-BODY PROGRAM ATTENDANCE: I fully understand that CSCVVSB and program partners recommend that anyone participating in any exercise/relaxation/social program, both in-person and virtual (online), check with their healthcare provider prior to participation to ensure that they are medically able to do so. Participation in any such program, both in-person and virtual (online), could result in injury or illness.

By electronically signing and submitting this document, I agree to release, waive, discharge and hold harmless CSCVVSB and its program partners, affiliates, employees, interns, officers, agents, independent contractors, volunteers and donors from any and all claims, actions, demands, liabilities, expenses (including attorneys’ fees) and losses arising from bodily injury or illness, including, but not limited to, wrongful death, loss of services, loss of consortium, and all other damages that may arise out of participation in the exercise program.

I have read and understand the waiver and release agreement.
Electronic Consent: Member Name*
First Last
Thank you! We look forward to having you as a member of our community.

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Home | Privacy Policy | Phone 805-379-4777

The Cancer Support Community Valley/Ventura/Santa Barbara provides professional programs of emotional support, education and hope for people affected by cancer at no charge so that no one faces cancer alone. We serve West San Fernando Valley and Santa Barbara and Ventura Counties. Our main office is in Westlake Village with a satellite in Winnetka and offsite programs in Sylmar, at Olive New UCLA Medical Center, and in Ventura, at Ventura County Medical Center. We are proud of our hospital partnerships with the Cancer Resource Center at Community Memorial Hospital in Ventura and at the Cancer Center at St John’s Regional Medical Center in Oxnard and St John’s Pleasant Valley in Camarillo. Our programs provide a full-range of support and education for adults and children with cancer, their loved ones, and caregivers. Programs are provided in English and Spanish and include in orientation, groups for cancer survivors, family groups, groups for people beyond the day-to-day fight, cancer specific groups such as brain tumors, gynecological cancer, breast cancer, prostate cancer, Leukemia/lymphoma and melanoma. We also offer Kids and Teen Circle for children and teens affected by cancer, bereavement groups, and a buddy program. We service over 40 Southern California cities including: Agoura Hills, Oxnard, Calabasas, Santa Barbara, Camarillo, Canoga Park, Simi Valley, Carpenteria, Sherman Oaks, Encino, Sylmar, Tarzana, Los Angeles, Thousand Oaks, Malibu, Valencia, Newbury Park, Oak Park, Van Nuys, Ventura, Newhall, Westlake Village, Winnetka, and Woodland Hills. CPI Solutions IT Consulting in Ventura, Los Angeles and San Bernadino

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New Member/Annual Visitor Information Form

New Member/Annual Visitor Information Form

Please complete the following about YOURSELF

Please complete the following about yourself or for the person you are here to support

The following information will ONLY be used for funding purposes and program assessment with NO identifying information.

Confidentiality & Member Safety Consent