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Professionals

Please help us better serve young adults affected by cancer!

You must complete the evaluation below for a valid re-order of "My Way."

Thank you!
"My Way" Professionals' Form
Name:
Institution:
Address:
Phone:
Fax:
E-mail Address:




You are:
If Other, please specify:
How many young adults (ages 15-39) do you see in your practice in the course of a year?
As a Patient?:
As a Family Member/Loved One?:
What issues/concerns do your young adult patients/clients most often raise?:
What are the demographics of your practice?
Male %:
Female %:
Age Range From-To:
Race
Caucasian %:
African-American %:
Asian/Pacific Islander %:
Native American/Alaskan Native %:
Other %:
Ethnicity
Hispanic %:
Non-Hispanic %:
What feedback have you received regarding "My Way"?:
Additional Comments:
How many copies of "My Way: Writings of Young Adult Cancer Survivors" would you like?:
Would you like Ulman Cancer Fund for Young Adults Bookmarks or Annual Newsletters included with your order?
a. Bookmarks?:
... How Many?:
b. Annual Newsletters?:
... How Many?:
For more information, contact Elizabeth Saylor at elizabeth@ulmanfund.org, or call 410-964-0202 x102 or 888-393-FUND (3863).

410-964-0202 888-393-FUND (3863) info@ulmanfund.org Home

DISCLAIMER: Information provided by the Ulman Cancer Fund for Young Adults (UCF) via this website is not intended to replace or supersede information received from medical, legal, or other professionals with regard to specific circumstances and concerns. UCF information is intended solely as a general resource. A licensed/certified professional should always be consulted regarding any medical, legal, or other pertinent issue regarding cancer diagnosis and treatment. The UCF accepts no responsibility or liability resulting from the use of information provided on this site.
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