Caregiver Registration

A caregiver is defined as a person who helps an individual diagnosed with cancer (within FIVE years of diagnosis) with daily living activities including assisting with medication, bathing, dressing, meal preparation, and doctor’s appointments.

  • Please provide your full name.
  • Primary email for contact by NVCCF.
  • Primary phone for contact by NVCCF.
  • If professional caregiver.
  • If professional caregiver.
  • I understand that as a caregiver, I will be permitted to participate in group activities with my participant. Individual sessions such as massage, reflexology and Reiki will be available on a limited basis as priority is given to cancer survivors and those currently in treatment. All answers and statements on this registration and any other materials I have submitted to apply as a particiapnt in The Caring Place programs and services are true and complete to the best of my knowledge. I understand that The Caring Place may verify this information. Untruthful or misleading answers are cause for rejection of this registration.
    Reset signature Signature locked. Reset to sign again
  • This field is for validation purposes and should be left unchanged.