Southwestern Ontario Chapter Meeting- Peer Support -Support Program - February 2, 2022

Support Program

Thank you for taking the time to register for the Southwestern Ontario Chapter Meeting on Wednesday, February 2, 2022 for a session of self-reflection and discovery that will identify your own unique ways of brining meaning and quality to your life throughout your cancer journey. Please fill out the following information for registration. A join link for the virtual session will be sent to you 2-3 days in advance of the meeting.

If you have any questions or experience any difficulty in completing this registration form, please contact kaitlyn@lymphoma.ca.

Question Title

* 1. Contact Information

First Name: *

Last Name:

City/Town:

ZIP/Postal Code: *

Email Address: *

Phone Number:

Question Title

* 2. Please indicate your interest in lymphoma (you may select all that apply).

I have Hodgkin lymphoma

I have Follicular lymphoma

I have Diffuse Large B-Cell lymphoma

I have Marginal Zone/MALT lymphoma

I have Mantle Cell lymphoma

I have CLL/SLL lymphoma

I have Burkitt's lymphoma

I have Waldenstrom's Macroglobulinemia lymphoma

I have Transformed lymphoma

I have Peripheral T-Cell lymphoma

I have Cutaneous T-Cell lymphoma

I have NK-Cell lymphoma

I know someone who has lymphoma

I do not know what kind of lymphoma I have

I have another type of lymphoma, not listed here

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* 3. Will you be bringing a guest?

Yes

Not Sure