REGISTRATION FORM REGISTER Username* E-mail Address* Password* Confirm Password* Password has to have a minimum of 8 characters, that include one upper case and two numbers, together or apart, anywhere Only fill in if you are not human Parents registering their child (under 18) are requested to fill in both the Adult & Child information. Information provided below will not be released and is not available to other members. Membership Profile Today's Date* Name of Adult:* Birth Date:* Email:* Choose Your Blood Type: 0+ 0- A+ A- B+ B- AB+ AB- ** (we are trying to find out if there is a connection between certain ailments and blood types) Childs Name: Birth Date: City:* State:* Zip Code:* Country:* Select Your Ailment (Choose one only):* Common Debilitating And Life Threatening Diseases Adenomas Adrenocortical Carcinoma AIDS-Related Cancers AIDS-Related Lymphoma Anal Cancer Angiosarcoma Appendix Cancer Astrocytoma, Childhood Cerebellar or Cerebral Basal-Cell Carcinoma B-Cell Lymphoma Bile Duct Cancer, Extrahepatic (See Cholangiocarcinoma) Bladder Cancer Bone Tumor, Osteosarcoma/Malignant Fibrous Histiocytoma Brainstem Glioma Brain Cancer Brain Tumor, Cerebellar Astrocytoma Brain Tumor, Cerebral Astrocytoma/Malignant Glioma Brain Tumor, Ependymoma Brain Tumor, Medulloblastoma Brain Tumor, Supratentorial Primitive Neuroectodermal Tumors Brain Tumor, Visual Pathway and Hypothalamic Glioma Breast cancer Bronchial Adenomas/Carcinoids Burkitt’s Lymphoma Carcinoid Tumor, Childhood Carcinoid tumor, gastrointestinal Carcinoid tumor, gastrointestinal Colon Cancer Chronic Myeloproliferative Disorders Chronic Myelogenous Leukemia Chronic Lymphocytic Leukemia Cervical Cancer Cerebral Astrocytoma/Malignant Glioma, Childhood Cerebellar Astrocytoma, Childhood Central Nervous System Lymphoma, Primary Carcinoma of Unknown Primary Carcinoid Tumor, Gastrointestinal Cutaneous T-cell Lymphoma Desmoplastic Small Round Cell Tumor Extragonadal Germ Cell Tumor Extrahepatic Bile Duct Cancer Eye cancer, Intraocular Melanoma Eye cancer, Retinoblastoma Endometrial Cancer Ependymoma Epithelial Squamous Carcinoma Esophageal Cancer Ewing’s Sarcoma In The Ewing Family of Tumors Extracranial Germ Cell Tumor, Childhood Fibrosarcoma Gallbladder Cancer Glioma, Childhood Visual Pathway and Hypothalamic Glioma, Childhood Cerebral Astrocytoma Glioma of The Brain Stem Glioma Meningiomas Gestational Trophoblastic Tumor Germ Cell Tumor: Extracranial, Extragonadal, or Ovaria Gastrointestinal Stromal Tumor (GIST) Gastrointestinal Carcinoid Tumor Gastric (Stomach) Cancer Gastric Carcinoid Hairy Cell Leukemia Head and Neck Cancer Heart Cancer Hepatocellular (Liver) Cancer Hodgkin Lymphoma Hypothalamic and Visual Pathway Glioma, Childhood Intraocular Melanoma Islet Cell Carcinoma (Endocrine Pancreas) Kidney Cancer Kaposi Sarcoma Laryngeal Cancer Leukemias Lung Cancer, Small Cell Lymphomas Lymphoma, AIDS-related Lymphoma B-Cell Lymphoma, Burkitt Lymphoma, Cutaneous T-Cell Lymphoma, Hodgkin Lymphomas, Non-Hodgkin (An Old Classification of All Lymphomas Except Hodgkin’s) Lung Cancer, Non-Small Cell Liver Cancer (Primary) Leukemia, Acute Lymphoblastic (Also Called Acute Lymphocytic Leukemia) Leukemia, Acute Myeloid (Also Called Acute Myelogenous Leukemia) Leukemia, chronic lymphocytic (also called chronic lymphocytic leukemia) Leukemia, Chronic Myelogenous (Also Called Chronic Myeloid Leukemia) Leukemia, Hairy Cell Lip and Oral Cavity Cancer Liposarcoma Lymphoma, Primary Central Nervous System Myeloproliferative Disorders, Chronic Multiple Myeloma/Plasma Cell Neoplasm Mycosis Fungoides Myelodysplastic Syndromes Myelodysplastic/Myeloproliferative Diseases Myelogenous Leukemia, Chronic Myeloid Leukemia, Adult Acute Myeloid Leukemia, Childhood Acute Myeloma, Multiple (Cancer of The Bone-Marrow) Multiple Endocrine Neoplasia Syndrome, Childhood Mouth Cancer Metastatic Squamous Neck Cancer With Occult Primary Mesothelioma, Childhood Mesothelioma, Adult Malignant Merkel Cell Cancer Melanoma, Intraocular (Eye) Macroglobulinemia, Waldenström Male Breast Cancer Malignant Fibrous Histiocytoma of Bone/Osteosarcoma Medulloblastoma, Childhood Melanoma Nasal Cavity and Paranasal Sinus Cancer Nasopharyngeal Carcinoma Neuroblastoma Non-Hodgkin Lymphoma Non-Small Cell Lung Cancer Oral Cancer Oropharyngeal Cancer Osteosarcoma/Malignant Fibrous Histiocytoma of Bone Ovarian Cancer Ovarian Epithelial Cancer (Surface Epithelial-Stromal Tumor) Ovarian Germ Cell Tumor Ovarian Low Malignant Potential Tumor Pancreatic Cancer Pancreatic Cancer, Islet Cell Papillomas Paranasal Sinus and Nasal Cavity Cancer Parathyroid Cancer Penile Cancer Pharyngeal Cancer Pheochromocytoma Pineal Astrocytoma Pineal Germinoma Pineoblastoma And Supratentorial Primitive Neuroectodermal Tumors, Childhood Pituitary Adenoma Plasma Cell Neoplasia/Multiple Myeloma Pleuropulmonary Blastoma Primary Central Nervous System Lymphoma Primitive Neuroectodermal Tumors Prostate Cancer Rectal Cancer Renal Cell Carcinoma (Kidney Cancer) Renal Pelvis And Urethra, Transitional Cell Cancer Retinoblastoma Rhabdomyosarcoma, Childhood Salivary Gland Cancer Sarcoma, Ewing Family of Tumors Sarcoma, Kaposi Sarcoma Synovial Sarcoma, Soft Tissue Sarcoma, Uterine Sézary Syndrome Skin Cancer (Non-Melanoma) Skin Cancer (Melanoma) Skin Carcinoma, Merkel Cell Small Cell Lung Cancer Soft Tissue Sarcoma Squamous Cell Carcinoma – See Skin Cancer (Non-Melanoma) Squamous Neck Cancer With Occult Primary, Metastatic Stomach Cancer Supratentorial Primitive Neuroectodermal Tumor, Childhood T-Cell Lymphoma, Cutaneous – See Mycosis Fungoides And Sézary Syndrome T – Cell Leukemia Testicular Cancer Throat Cancer Thymoma, Childhood Thymoma And Thymic Carcinoma Thyroid Cancer Thyroid Cancer, Childhood Transitional Cell Cancer of The Renal Pelvis And Ureter Trophoblastic Tumor, Gestational Unknown Primary Site, Carcinoma of, Adult Unknown Primary Site, Cancer of, Childhood Ureter And Renal Pelvis, Transitional Cell Cancer Urethral Cancer Uterine Cancer, Endometria Uterine Sarcoma Vaginal Cancer Vestibular Schwannomas Visual Pathway And Hypothalamic Glioma, Childhood Vulvar Cancer Waldenström Macroglobulinemia Wilms Tumor (Kidney Cancer), Childhood For How Long Have You Had This Ailment: Present (for up to 3 months) Under Treatment & Observation (from 3 months to 2 years) Past (for over 2 years) "SURVIVOR" NOTE: If you have more than one ailment you need to fill-in a different membership profile form per ailment. You must use the same User ID and Password for all. Parents registering their child (under 18) are requested to fill in both adult and child sections. These forms are strictly kept with the most privacy and will not be released under any condition, except by Court Order. **For our purpose, a “Past” ailment is one that, after treatment, has not returned for over two years, or has been stabilized for over two years, or that you have been able to manage it for over two years, in which case you can click on it as your choice. You can cancel your registration at any time by deleting your account.