Donate
Home
About the LRG
Patient Support
LRG Research
LRG Library
Medical Professionals
The Life Raft Group - Ensuring that no one has to face GIST alone The Life Raft Group - Ensuring that no one has to face GIST alone
My name is Jim. I like to spend time with my wife Lori and I love to play golf.
My name is Jim. I like to spend time with my wife Lori and I love to play golf.
The Life Raft Group - Ensuring that no one has to face GIST alone
About GIST
Frequent Topics
Accessing Treatment
Coping with Cancer

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
How did you find out about the Life Raft Group?
Specify
How would you like to participate in our Email Community? Subscription Details
CONTACT INFORMATION FOR MEMBER APPLICANT
Please provide us with either a home or work contact information.

Primary Home Work
Address

City
State
Zip
Country
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 :

 

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

Get more info about The Patient Registry
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
Country
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
 
Not readable? Change text.

 
Please enter code from above
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.

This website is accredited by Health On the Net Foundation. Click to verify. We subscribe to the HONcode principles. Verify Here
This website is dedicated in perpetuity to the memory of Mary S. Golnik
JT IMAGES, Inc. - Website designer
© Copyright 2009 Life Raft Group. All rights Reserved.
Last Modified - November 23, 2011 2:28pm
View the Life Raft Group Policies and Disclaimer