Registration Form | SurvivingBreastCancer.org

First name

Last name

Email

Street Address

City

State

Country

Postal Code

When were you diagnosed with breast cancer?

Other (Please Specify)

To the best of your knowledge, which of the following are/were included in your breast cancer treatment plan?

Chemotherapy: intravenous

Chemotherapy: oral

Immunotherapy

Surgery: mastectomy

Surgery: lumpectomy

Surgery: not sure what type of surgery yet

Radiation

Not sure of my treatment

What stage breast cancer were you diagnosed with?

As of April 1, 2026, where will you be in your chemotherapy treatment?

As of April 1, 2026, where will you be in your surgery treatment?

As of April 1, 2026, where will you be in your radiation treatment?

Anything else you’d like us to know about your breast cancer diagnosis and/or treatment?

I understand this is an 8-week cohort program meeting on the following dates: April 1, 10:00am-11:30am ET April 8, 10:00am-11:30am ET April 15, 10:00am-11:30am ET April 22, 10:00am-11:30am ET April 29

I understand

I have reviewed the dates and times and intend to attend each session, knowing that my participation supports both my own experience and the group, this program is not drop-in. Each week builds on the

I agree

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ACCESS: an 8-week breast cancer cohort program

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ACCESS: an 8-week breast cancer cohort program