Registration Form
Name
Age
Address
Telephone
Cell Phone
Have you any personal experience of cancer?		Yes	No
If Yes
As Caregiver	As Survivor	As Physician
Can you volunteer time?		Yes	No
If yes, please specify time you can realistically devote:
Hour/s per week		Day/s per month
In what area would you like to work?
Cancer Jagruti (Cancer Awareness Talks / Schools programmes / Community work)
Cancer Sahyog (Emotional Support /Hospital work)
CanKids (working for children with cancer)
Fund-raising
Advocacy / Liaison with Govt./other agencies
Media relations and PR
Creative work to take cancer awareness to every home.
Other : Please specify.
IT skills