YASU Survivor Membership Price: Free First Name:* First Name Required Last Name:* Last Name Required Address Line 1:* Address Line 1 is Required Address Line 2: Address Line 2 is not valid City:* City is Required Country:* Country is Required -- Select Country -- Afghanistan Åland Islands Albania Algeria Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belau Belize Benin Bermuda Bhutan Bolivia Bonaire, Saint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo (Brazzaville) Congo (Kinshasa) Cook Islands Costa Rica Croatia Cuba CuraÇao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Republic of Ireland Isle of Man Israel Italy Ivory Coast Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao S.A.R., China Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palestinian Territory Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthélemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Martin (Dutch part) Saint Pierre and Miquelon Saint Vincent and the Grenadines San Marino São Tomé and Príncipe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia/Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom (UK) United States (US) Uruguay Uzbekistan Vanuatu Vatican Venezuela Vietnam Wallis and Futuna Western Sahara Western Samoa Yemen Zambia Zimbabwe State/Province:* State/Province is Required Zip/Postal Code:* Zip/Postal Code is Required County of Residence: County of Residence is not valid Phone Number:* Phone Number is Required Email Address:* Email Address is Required Facebook Account Name (So we can add you to our private group): Facebook Account Name (So we can add you to our private group) is not valid Date of Birth:* Date of Birth is Required Diagnosis:* Diagnosis is Required Acute Lymchoblastic LeukemiaAcute Myeloid LeukemiaBrain CancerBreast CancerCervical CancerChronic Lymphocytic LeukemiaChronic Myeloid LeukemiaColon CancerColorectal CancerHodgkins LymphomaMelanomaMultiple MelenomaNeuroendocrine CancerNon-Hodgkins LymphomaOvarian CancerSarcomaTesticular CancerThymoma CancerThyroid CancerUterine CancerOther Diagnosis (Other): Diagnosis (Other) is not valid Date of Diagnosis:* Date of Diagnosis is Required Gender: Gender is not valid MaleFemaleTransgenderNon-Binary/Non-ConformingPrefer Not To SayOther Gender (Other): Gender (Other) is not valid Race: Race is not valid African-AmericanAsianHispanic or LatinoCaucasianNative AmericanOtherPrefer Not To Say Race (Other): Race (Other) is not valid Ethnicity: Ethnicity is not valid Hispanic or LatinoNot Hispanic or LatinoPrefer Not To Answer Programs of Interest: Programs of Interest is not valid Support Groups Social Activities Financial Assistance Educational Workshops Marital Status:* Marital Status is Required MarriedWidowedDivorcedSeparatedDomestic Partnership or Civil UnionSingle, Cohabitating with Significant OtherSingle, Never Married Household Members: Household Members is not valid 123456+ Household Members Under 18: Household Members Under 18 is not valid 1234+None Household Income (Annual): Household Income (Annual) is not valid Less than $20,000$20,000-$50,000$50,000-$100,000$100,000-$150,000$150,000-$200,000More than $200,000 How did you hear about us?: How did you hear about us? is not valid WebWord of MouthFacebookInstagramTwitterMedical FacilityOther How did you hear about us? (Other): How did you hear about us? (Other) is not valid Hospital Affiliation:* Hospital Affiliation is Required Add me to the email list for program, event, and volunteer announcements YASU Program:* YASU Program is Required Young Adult Cancer Support Group (NATIONAL)Young Adult Cancer Support Group (LOCAL)Co-Survivor Support Group Email:* Invalid Email Password:* Invalid Password Password Confirmation:* Password Confirmation Doesn't Match Password Strength No val Please fix the errors above Christopher Kanski2023-05-24T15:34:18-05:00
