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Living Well With And Beyond Melanoma - Registration Form
Please note that this course is intended
ONLY
for patients who have completed their treatment for
ADVANCED
(stage 3 or 4) melanoma to provide skills to live well after treatment.
*
1.
Please enter your full name
(Required.)
*
2.
Please enter your email address
(Required.)
*
3.
Please select your age group
(Required.)
Under 18
18-25
26-35
36-45
46-55
56-65
Over 65
*
4.
Please select your gender
(Required.)
Male
Female
Non-binary
Gender neutral
Transgender
Prefer not to say
*
5.
What is your stage of melanoma?
(Required.)
*
6.
What type of melanoma do you have?
(Required.)
Cutaneous (skin) melanoma
Acral lentiginous melanoma
Mucosal melanoma
Uveal melanoma
*
7.
Please outline the treatment(s) you have had for melanoma
(Required.)
*
8.
How long has it been since you completed your last treatment for advanced melanoma?
(Required.)
Less than 6 months
Between 6 months and 1 year
Between 1 and 2 years
Between 2 and 5 years
Over 5 years
*
9.
Which region are you in?
(Required.)
Scotland
Wales
Northern Ireland
East of England
East Midlands
London
North East
North West
South East
South West
West Midlands
Yorkshire and the Humber
*
10.
What is your sexual orientation?
(Required.)
Asexual
Bisexual
Gay
Heterosexual
Lesbian
Pansexual
None of the above
Prefer not to say
*
11.
What is your ethnicity?
(Required.)
White - English/Welsh/Scottish/Northern Irish/British
White - Irish
White - Gypsy or Irish Traveller
White - Eastern European
White – any other White Background
Mixed descent – White and Black African
Mixed descent – White and Black Caribbean
Mixed descent – White and Black Asian
Mixed descent – Any other mixed
Asian – Indian
Asian- Pakistani
Asian- Bangladeshi
Asian – Chinese
Any other Asian ethnicity
Black – African
Black – Caribbean
Any other Black
Arab
Any other ethnic group
Prefer not to say
*
12.
Would you be willing to complete a questionnaire before and after the course?
(Required.)
Yes
No
