Fall Family Cancer Retreat Registration

Please use the following form to begin your registration for the retreat. You can view the details of the event on the Family Cancer Retreat page. Please provide all requested information for all participants. Note, all participants must be at least 14 years old. This information will be kept confidential to Cancer Services of New Mexico.

Fields marked with an * are required

Patient Name *

Email Address *

Confirm Email Address *

Street/Mailing Address *

City *

State *

Zip Code *

County *

Primary Phone # *

Alternate Phone #

Gender *

Age *

Type of cancer *

Year of Diagnosis *

Oncologist's Name*

Oncologist's Phone #*

Briefly describe your current treatment regimen*

Military veteran *

Who should we contact regarding this reservation?*

Contact Phone # *

Relationship to patient *

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 Family Members/Friends will participate? (Must be 14 or older) *

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.)

* In making this registration for Cancer Services of New Mexico's Fall 2024 Family Cancer Retreat, I state that the foregoing information is complete and accurate to the best of my knowledge. I authorize my oncologist and his/her representatives to release information regarding my ability to participate in the Fall 2024 Family Cancer Retreat to Cancer Services of New Mexico or its agents and employees. I release from all liability all individuals and organizations that provide information about me regarding this registration form.

Fall Family Cancer Retreat Registration

Cancer Retreat Supporters