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REHABILITATION PROGRAMME APPLICATION FORM
First Name
Last Name
Email
Code
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Phone
Street Address
Region/State/Province
Age
Have you received a cancer diagnosis?
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Are you currently preparing or undergoing treatment?
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Are you recovering from the debilitating effects and fatigue that treatment often brings?
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Are you taking any other medication subscribed by Doctors / Medical Practitioners?
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How would you like to attend weekly sessions?
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Street Address Line 2
Country
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City
Postal / Zip code
What is your diagnosis?
What treatment are you currently going through. Please provide details
Do you have any issues / restrictions to your body due to treatment?
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Please provide details of any issues / restrictions you are experiencing
Please provide details of all medication you are currently taking
Have you been given permission by your medical team to resume physical exercise?
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Are you struggling financially due to your diagnosis?
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We are currently only accepting applicants who are over 18 years old, please confirm this by ticking box that you are above 18 years old.
SUBMIT YOUR APPLICATION
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