Share your story with us

First name

Last name

Email

Phone number

Suburb

Date of Birth

Are you a

Cancer patient or survivor
Carer
Other (please specify)

If other, please specify (optional)

What type of cancer have you been diagnosed with? (optional)

When were you diagnosed with cancer? (optional)

Can you summarise your cancer experience? (optional)

Do you have a family history of cancer? (optional)

Yes
No

Who else in your family has been diagnosed with cancer? (optional)

Who did you care for? (optional)

Can you describe the experience of caring for someone with cancer? (optional)

Can you explain how you and your loved ones have been impacted by cancer? (optional)

Have you or your loved ones used Cancer Council’s information or support services?

Yes
No

Which information or support services have you or your loved one used? (Select all that apply) (optional)

If other, please specify (optional)

Have you participated in media interviews before?

Yes
No

Please summarise your media experience. (optional)

Is there any other interesting information about you or your family that you'd like to share with us? Write or upload your story here

Upload your story (optional)

Do you fundraise or volunteer for a Cancer Council Victoria event or campaign?

Yes
No

Which campaign/s are you registered for? (optional)

If other, please specify (optional)

If relevant, please describe your event. (optional)

By completing this form and sharing your story with us you have provided Cancer Council Victoria with your personal information. We may also collect further personal information about you through our ongoing communication.

Cancer Council’s Privacy Policy and Collection Statement contains general information about how we will handle and hold your personal information, and how you can contact us to seek to access or correct your personal information or make a complaint.

In addition to the uses and disclosures described in our Privacy Policy and Collection Statement, we will use and disclose your personal information to contact you to find out more about your cancer experience and to see what activities you’d like to be involved in.

By submitting this form, I agree to Cancer Council Victoria collecting and holding my personal and health information in accordance with its Privacy Policy and Collection Statement, and using such information to contact you about your cancer experiences.

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