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OUR STORY
THE NATIONAL LOTTERY AWARD
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CANCER REHABILITATION CENTRE
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REHABILITATION PROGRAMME APPLICATION FORM
First Name
Last Name
Email
Code
Phone
Street Address
Region/State/Province
Age
Have you received a cancer diagnosis?
Are you currently preparing or undergoing treatment?
Are you recovering from the debilitating effects and fatigue that treatment often brings?
Are you taking any other medication subscribed by Doctors / Medical Practitioners?
How would you like to attend weekly sessions?
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Country
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?
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?
Are you struggling financially due to your diagnosis?
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.
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