Your contact details
Title *
Please select ... Mr Mrs Miss Ms Other
First name *
Last name *
Address 1 *
Address 2
Address 3
Postcode *
Contact phone number *
Email address *
Confirm email *
Your background
Gender *
Please select ... Male Female
Date of birth *
Ethnicity (knowing your ehtnic background can help us to show that people from all backgrounds are affected by cancer)
Please select ... White British White other Mixed white and black Caribbean White and black African White and Asian Other mixed Indian Pakistani Bagladeshi Other Asian Carribean African Other black Chinese Other
Marital status
Please select ... Married Single Divorced Separated Co-habiting Civil Partnership Widowed
Do you have any children or grandchildren?
Your health history
Your link to cancer (have you had cancer, are you currently living with cancer or do you have a close friend or relative with cancer?) *
How would you describe your current health? *
Type of cancer *
Date of diagnosis *
How was your cancer detected?
Do you need further treatment?/How often do you see your doctor? *
Have you been for genetic testing? If yes, what was the outcome?
Do you have a family history of cancer?
Have you taken part in a clinical trial? If yes, please provide a brief outline (e.g. name of trial, dates, location, etc)
Your lifestyle (e.g. smoker, take regular exercise)
Your story
Please provide a brief outline of your experience of cancer *
What's motivated you to share your story with Cancer Research UK?
Are you happy to be named, pictured and identified by your town in media activity? *
Please select ... Yes No
Have you been involved in any publicity relating to your cancer experience before? If yes, please provide details. *
How did you hear about share your story? *
Please select ... Media Cancer Research UK online Cancer Research UK printed materials Friend/relative Other
If you have had contact with Cancer Research UK before about sharing your story please state who it was with
Cancer Research UK would like to keep you up to date with details of news, events and fundraising activities using the contact details you have supplied.
