Join the community

Donor Short Form

Tell us a little about yourself so we can connect you with the most relevant support, activities, and community spaces. Most questions are optional — you only need to share what feels comfortable.

Donor Short Form

Welcome to Cancer Support Netherlands (CSN)

Whether you're supporting a loved one through cancer, caring for someone, or navigating the impact of cancer within your family or friendship circle, we hope CSN can be a place of connection, understanding, and support.

his form helps us get to know you a little better so we can connect you with the most relevant support, activities, and community spaces. Most questions are optional, and you only need to share what feels comfortable for you.

Everything you share will be treated with care and confidentiality.

About You

Name *

Preferred Name/ Pseudonym First Name Last Name

If you choose to use a preferred name, we will use it to address you in all community spaces, emails, and groups. Your privacy is our priority, so we only use your legal name for secure account verification and billing.

Date of Birth

dd-MMM-yyyy

Gender

Male Female Prefer not to say Other

Are you comfortable communicating in English and participating in English-language conversations and events? *

Yes No

Our community activities, communications, and events are currently conducted in English.

Do you live in or have a strong connection with the Netherlands? *

Yes No, but the person I'm supporting with cancer does

While Cancer Support Netherlands mainly serve those who live in the Netherlands, we welcome anyone with has strong ties with the Netherlands, such as having family here or having lived here for many years

Where do you live? *

Street Address

City

Postal / Zip Code Country

This helps us find and suggest local peers, neighbourhood events and in-person support near you.

Your Connection to Cancer

Is the person you support currently:

Which option best describes their current situation?

What type of cancer has affected your loved one?

Your Contact Information

Email *

Phone *

Code Number

Please enter the number that could be reached via Whatsapp

Preferred Method of Communication

Email Phone

Getting Connected

How do you prefer to stay connected as a CSN member? *

(Select all that apply)

Would you like to connect with a local hive? (WhatsApp only)

Yes No Maybe later

This is only applicable for people living within the Netherlands.

Which CSN activities and community spaces would you be interested in?

Social meet-ups Webinars (online educations talks/workshops) Wellbeing activities (e.g. walks) Online community groups (e.g. WhatsApp or Facebook groups) Email Newsletters All of the above

(Select all that apply)

Would you like a short welcome call with a member of the CSN team? *

Yes No Maybe later

This is simply an opportunity to learn more about the community, ask questions, and help us connect you with the support that feels right for you.

What would you most like to gain from being part of this community?

Would you be interested in volunteering within the CSN community?

Yes Maybe in the future No

Accessibility or Participation Needs

Is there anything that would help make events, activities, or community participation more accessible or comfortable for you?

Anything Else You'd Like Us to Know?

Is there anything you'd like to share about your experience, circumstances, or support needs that may help us welcome and support you?

I give permission for the community organization to use my information for community-related communications or events. *

I have read and agree to abide by the community's rules and guidelines. *

I agree to keep information within the community spaces (including names of other members and their information) confidential *

Signature

Thank you for joining the community.

Supporting someone affected by cancer can be rewarding, challenging, and at times overwhelming. We hope this community can offer connection, understanding, and support for you as well as for those you care about.