Virtual Cancer Retreat Registration

Registration is required to participate in the retreat. Please use the following form to complete your registration. You can view the details of the event on the Virtual Retreat page.

Fields marked with an * are required

Are you a: *

Name *

Email Address *

Confirm Email Address *

City *

State *

County *

Gender *

Racial Group *

Age *

Type of cancer *

Year of Diagnosis *

Military veteran *

Is the cancer patient/survivor you support registered for the retreat?*

What type of cancer does the patient you care for have? *

How many additional people will participate from your location? *

Have you been to a Cancer Services of New Mexico retreat before? *

Where did you learn about the retreat? * (e.g. Hospital, Website, Social Media, Friend, etc.)

At which hospital or clinic do you recieve treatment? *

* I understand that all information and advice provided during the Cancer Retreat are the opinions of the presenters, and do not necessarily reflect the views and beliefs of Cancer Services of New Mexico. I agree that I will not hold Cancer Services of New Mexico responsible for any injuries or damages that occur as a result of my acting on information provided during the Virtual Cancer Retreat.

* I understand the contents of the retreat may be recorded and made available to the general public and/or the media. I grant permission for my appearance in voice, video or written comments recorded during the program to be used in any publications and/or media campaigns resulting from participation in the Virtual Cancer Retreat.

Virtual Cancer Retreat Registration

Cancer Retreat Supporters