Cancer Exercise Program Qualification Form

Initial Questions

Client Information

1. Client First Name: *This question is required.

2. Client Last Name: *This question is required.

3. Date of Birth: *This question is required. This question requires a valid date format of MM/DD/YYYY.

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4. Current Age: *This question is required.

6. Home Phone Number:

7. Cell Phone Number:

8. Mailing Address: *This question is required.

9. City: *This question is required.

10. State: *This question is required.

11. ZIP Code: *This question is required.

12. Email Address: *This question is required. This question requires a valid email address.

Program Qualifying Questions

13. Are you currently being treated at the University of Colorado Cancer Center?

14. Are you currently undergoing treatment or no more than 6 months post treatment (chemotherapy, radiation, surgery, etc.)?