Life Raft Group
Membership Application Form

Dear Life Raft Group Applicant,

Thank you for your interest in joining the Life Raft Group (LRG). We are a group of GIST patients (plus their caregivers & families) who have come together to share our medical experiences and to provide each other with support.  Our mission is to ensure that no one faces GIST alone. Membership to the LRG is free and it will provide you with tools to guide you through your GIST journey.

Membership Benefits

• Membership in a private, secure email community (listserv), maintained by the Association of Online Cancer Resources (ACOR), where you can meet and communicate with others and share information.
• Access to monthly newsletters which provide the latest information and education about GIST and its treatments.
• Membership package sent via mail filled with important information for your GIST care management. GIST management information can also be sent to your doctor, upon request.
• Free personal consultations about GIST management, clinical trial navigation and other areas.*
• Enrollment in a sophisticated GIST patient registry which produces cutting edge research on the latest medical trends among GIST patients.
• Connection with other GIST patients and caregivers in your local area.

Privacy

Our primary concern is the privacy of our members. The LRG does not send information that might be considered private to anyone outside of the group. To help ensure that goal, we restrict membership in our group to GIST survivors and caregivers. 

Disclaimer

*We are patients and caregivers, not doctors. Any information shared among the group should be used with caution, and is not a substitute for careful discussion with your doctor.

Please let us know if you have any questions or comments. We look forward to hearing from you and will let you know as soon as possible if your membership is delayed (Note: Reasons for delay might include: identifying information and diagnosis details are missing from application).

Norman J. Scherzer
Executive Director

If you have any problems filling out this application, please call us at (973) 837-9092

APPLICANT INFO *Denotes required field
*Last Name *First Middle Init Patient's Name (If Different) The Patient Is My [Select One] SelfHusband / WifeParentBrother / SisterChildSignificant OtherCaregiverOther How did you find out about the Life Raft Group? [Select One] InternetDoctorLRG MemberOther Specify How would you like to participate in our Email Community? [Select One] RegularDigestI do not wish receive listserv emails Subscription Details
CONTACT INFORMATION FOR MEMBER APPLICANT Please provide us with either a home or work contact information. Primary Home Work Address City State [Select State] [Not Applicable] AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabridorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon [Select State] [Not Applicable] AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabridorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Zip Country United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)Congo, Democratic Republic of theCosta RicaCroatiaCubaCyprusCzech RepublicCote dIvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSlovakiaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaYemenZambiaZimbabwe United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)Congo, Democratic Republic of theCosta RicaCroatiaCubaCyprusCzech RepublicCote dIvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSlovakiaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaYemenZambiaZimbabwe Phone Fax *Email (required) Our experience is that Internet Service Providers often experience breakdowns or block access to list discussion groups, and we would like a second e-mail address to contact you should this occur Email 2 *Preferred contact method : [Select One] maile-mailphonefaxOther   PATIENT REGISTRY OPTIONS We utilize the data from this registry to identify critical areas not being covered in a timely way by clinical trials or by the traditional cancer research community, we de-identify your personal info to comply with HIPAA privacy Would you like to participate in our Patient Registry? YES    NO, Contact Me Later
ABOUT THE PATIENT Complete the information below for the patient if you would like to participate in our Patient Registry Please fill out the application to the best of your knowledge. If you cannot answer any question completely, leave it blank and an LRG staff member will contact you to follow up. PERSONAL DETAILS ABOUT PATIENT Marital Status [Select One] MarriedSingleDivorcedWidowedSeparatedOther Gender [Select One] MaleFemale Ethnicity [Select One] American Indian or Alaskan NativeAsian or Pacific IslanderBlack, not of Hispanic originHispanicWhite, not of Hispanic originUnknown Date of Birth City State [Select State] [Not Applicable] AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabridorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Country United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)Congo, Democratic Republic of theCosta RicaCroatiaCubaCyprusCzech RepublicCote dIvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSlovakiaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaYemenZambiaZimbabwe MEDICAL HISTORY DIAGNOSIS GIST Diagnosis Date (date that you were diagnosed with GIST) Were you previously misdiagnosed? YES    NO, if so enter the date  Please provide us details about your Primary Tumor (i.e. How many tumors, location, general size and/or exact measurement) METASTASIS/METS/LOCAL RECURRENCE Have you had a Local Recurrence? YES  NO, if so, enter the date  Have you had Mets? YES  NO, if so, enter the date     Please provide us details about your Local Recurrence or Mets (if any) (i.e. How many tumors, location, general size and/or exact measurement, etc) Please tell us if you have any pre-existing conditions (i.e. diabetes, heart problems, blood pressure, other cancer diagnosis, family history of cancer, etc) C-KIT/CD-117 TEST (GIST diagnoses tipically confirmed by a C-kit test) Have you had C-Kit/CD-117 testing done? Yes No Date of C-Kit Test     Results [Select One] PositiveNegative    MUTATIONAL TEST (Most patients will not have an Amino Acid with their mutational analysis) Have you had mutational testing done? Yes No If yes, please provide: Date: Gene: [Select One] KitPDGFRAWild TypeOtherUnknown Exon: Amino Acid:    GLEEVEC PLASMA/BLOOD LEVEL TESTING For Gleevec Patients Only: Have you had plasma/blood testing done? Yes No If yes, please provide:    Test Date:   Trough Level: mg/ml   TREATMENT SURGERY DETAILS Date Reason Clear Margin Tumor Rupture Would you like to participate in our Tissue Bank Program: Yes No Primary TumorLocal RecurrenceMetastasisOther YesNoI do not know YesNoI do not know Primary TumorLocal RecurrenceMetastasisOther YesNoI do not know YesNoI do not know Primary TumorLocal RecurrenceMetastasisOther YesNoI do not know YesNoI do not know Please provide us your surgery's details(i.e. type of procedure, complications, etc)   MEDICATION DETAILS Please provide us a chronological history of the medications you've been taking to treat GIST Medication Dosage (mg/day) Start Date End Date Remarks [Select One] GleevecSutentAMN107(Tasigna)CNF-2024(Biogen)PerifosineBAY 43-9006(Nexavar)DoxorubicinIPI-504OSI-930AZD2171(Recentin)RAD001BMS-354825(Sprycel)AMG706(Amgen)Rapamycin/sirolimusGemcitabine(Gemzar)Ifosfamide(Baxter)PKC412Temozolomide(Temodal)Other       [Select One] GleevecSutentAMN107(Tasigna)CNF-2024(Biogen)PerifosineBAY 43-9006(Nexavar)DoxorubicinIPI-504OSI-930AZD2171(Recentin)RAD001BMS-354825(Sprycel)AMG706(Amgen)Rapamycin/sirolimusGemcitabine(Gemzar)Ifosfamide(Baxter)PKC412Temozolomide(Temodal)Other       [Select One] GleevecSutentAMN107(Tasigna)CNF-2024(Biogen)PerifosineBAY 43-9006(Nexavar)DoxorubicinIPI-504OSI-930AZD2171(Recentin)RAD001BMS-354825(Sprycel)AMG706(Amgen)Rapamycin/sirolimusGemcitabine(Gemzar)Ifosfamide(Baxter)PKC412Temozolomide(Temodal)Other     Please provide us additional medication details (i.e. other drugs, compliance, drug combination, etc) Additional Treatments Please describe any other treatment(i.e. RFA, Chemo, Embolizations, Ablation, dates, results, etc) Clinical Trial Details (If Applicable) If you are part of a clinical trial, include the trial site, trial doctor, city, state, and country Trial Site Trial Doctor City State [Select State] [Not Applicable] AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabridorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Country United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)Congo, Democratic Republic of theCosta RicaCroatiaCubaCyprusCzech RepublicCote dIvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSlovakiaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaYemenZambiaZimbabwe Dr.'s E-Mail Phone
DOCTOR & CLINICAL INFORMATION We use this information to help other GIST patients find doctors with GIST expertise and educate doctors who may not yet have that expertise.
Information About the oncologist who treats your GIST Name Facility Address City State [Select State] [Not Applicable] AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDistrict of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabridorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Country United StatesAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo (Brazzaville)Congo, Democratic Republic of theCosta RicaCroatiaCubaCyprusCzech RepublicCote dIvoireDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and The GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSlovakiaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWestern SaharaYemenZambiaZimbabwe Dr.'s E-Mail Phone
COMMENTS AND NOTES
Please tell us something about yourself or the patient professionally and/or personally. Include any special skills or interests. Other General Remarks or Questions
SUBMISSION
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All information provided will be kept strictly confidential and is for the internal use of the Life Raft Group only. We are committed to protecting the privacy of our members. Any data or information that we share in any way is always cleansed of identifying information in order to protect confidentiality.