Welcome to Trekstock - we can offer you great ways to connect with others living with cancer. Attend our interactive workshops, pop in for a cuppa and join our events in the UK.
We’d love to grab a few details from you. This data will be used for internal monitoring and will occasionally will be anonymised and used for promotion. All data will be treated as strictly confidential and subject to the provisions of the Data Protection Act 1998

I’m here if you have any questions.

Jemima, Health Support & Engagement Officer - health@trekstock.com
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Full Name *

 
Address

 
Address Line 1 *

 
Address Line 2

 
Town/City

 
postcode *

 
Date of Birth *

 
Contact Number *

 
What is your preferred means of communication? *


 
Trekstock would like to contact you about relevant upcoming programmes, events, and opportunities, including opportunities to fundraise for us. Please indicate if you are happy for us to contact you about this.

     
 
Emergency contact details

 
Name *

 
Relationship to you *

 
Contact Number *

 
Your diagnosis

 
Age at diagnosis *

 
Type of cancer *

 
Treatment stage *

 
Primary treatment centre/hospital *

 
What is your ethnicity?

This question is about the group to which you perceive you belong, which might not be the same as your nationality or place of birth. If other, please specify in the 'other' box.
 
White

If other, please specify in 'other' box

 
Mixed/multiple ethnic groups

If other, please specify in 'other' box

 
Asian/Asian British

If other, please specify in 'other' box

 
Black/African/Caribbean/Black British

If other, please specify in 'other' box

 
Other ethnic group (please specify)

 
Prefer not to say

     
 
How did you hear about Trekstock? *


 
What is the name and/or profession of the health care professional who told you about Trekstock?

 
What is the name of the charity that told you about Trekstock?

 
Which hospital/treatment centre was the poster?

 
Please detail which social media platform or online resource

If other, please outline in the 'other' box.

 
What areas do you feel you need support in?

tick all that apply. If other please fill in other box

 
If you would like to, please provide us with more information about how you would like to get support

 
Share your story

Feel free to share anything you would like to about your journey
 
If you would like your story to be shared on the Trekstock Network page, please upload a photo of yourself.

 
This data will be used for internal monitoring and will occasionally be anonymised and used for promotion. All data will be treated as strictly confidential and subject to the provisions of the Data Protection Act 1998.  Please indicate if you are happy for your form to be used in this way. *

     
Thank you for completing our form, and welcome to the Trekstock community!

If you would like, you can now join our private Facebook group: https://www.facebook.com/groups/874625719235550/

We will be in touch with you soon.

If you know of any friends who may want to get involved, please pass along this form!
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