Cancer Council Victoria Learning Hub
Preventing Cancer • Empowering Patients • Saving Lives
Research, education and health professionals registration form
Staff and volunteer registration form
Person affected by cancer registration form
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How are you affected by cancer?*
I am employed in a workplace with staff member/s who has/have or previously had cancer
I have cancer
I’ve had cancer
Support person for someone with cancer
Title
Field of teaching/research*
Nursing
Breast Care
Cancer Nursing
Lung Cancer
Nursing (general)
Paediatric oncology
Palliative Care
Prostate
Counselling
Dietetics
General Practice
Medical Oncology
Occupational Therapy
Palliative Care Consulting
Pathology
Pharmacy
Physiotherapy
Psychiatry
Psychology
Radiation Oncology
Radiation Therapy
Radiology
Social Work
Surgery
Other
Field of study*
Nursing
Breast Care
Cancer Nursing
Lung Cancer
Nursing (general)
Paediatric Oncology
Palliative Care
Prostate
Counselling
Dietetics
General Practice
Medical Oncology
Occupational Therapy
Palliative Care Consulting
Pathology
Pharmacy
Physiotherapy
Psychiatry
Psychology
Radiation Oncology
Radiation Therapy
Radiology
Social Work
Surgery
Other
Level of degree*
Undergraduate
Postgraduate
PhD
Other
Occupation*
Administration
Nurse Unit Manager
Breast Care Nurse
Cancer Nurse
Lung Cancer Nurse
Nursing (general)
Paediatric Oncology Nurse
Palliative Care Consultant
Prostate Nurse
Counsellor
Dietitian
GP
Medical Oncologist
Occupational Therapist
Palliative Care Nurse
Pathologist
Pharmacist
Physiotherapist
Psychiatrist
Psychologist
Radiation Oncologist
Radiation Therapist
Radiologist
Social Worker
Surgeon
Other
Nurse
Cancer type*
Acute myeloid leukaemia
Bowel cancer
Breast cancer
Cancer of unknown primary
Endometrial cancer
Head and neck cancers
High-grade glioma cancer
Liver cancer
Lung cancer
Hodgkin lymphoma
Melanoma
Non-melanoma (basal / squamous cell carcinoma)
Oesophagogastric cancer
Ovarian cancer
Pancreatic cancer
Peritoneal mesothelioma
Pleural mesothelioma
Prostate cancer
Sarcoma
State*
ACT
NSW
QLD
NT
SA
TAS
VIC
WA
Age group*
0-17
18-30
31-45
46-60
61-75
76+
Gender*
Female
Male
Prefer to self-describe
Prefer not to say
Do you identify as Aboriginal and/or Torres Strait Islander?*
Yes
No
Prefer not to say
How did you find out about Cancer Council Victoria eLearning courses?*
Email promotion (Cancer Council Victoria)
eNewsletter (Cancer Council Victoria)
From a Cancer Council nurse on 13 11 20
From a health professional involved in your treatment
Word of mouth (family/friend/colleague)
Poster or flyer
Media (radio, newspaper)
Social media (Facebook, Twitter, Instagram)
Other
Would you like to receive email updates from Cancer Council Victoria?*
Yes
No
By clicking on Register, you:
acknowledge that Cancer Council Victoria will collect the information above (including any personal or sensitive information), for the purposes of providing you with services or enabling any related communications, in accordance with the
Cancer Council Collection Statement
; and
consent to Cancer Council Victoria handling your personal and sensitive information in accordance with its
Privacy Policy
.
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