Class Details

Class Type

Class Content

Details

Speaker

Class Status

At Capacity

TRUEFALSE

Pack Class

TRUEFALSE

Day

Date

Start Time

End Time

Region

Venue

Class is at Full Capacity

We are sorry but this class is at full capacity. You can search for another class using the 'Book A Class' button at the top right of your screen. Please select another class or call 0800 865 432 or email info@cancersupport.org.nz

Class is Cancelled or Postponed

We are sorry but this class is no longer available. You can search for another class using the 'Book A Class' button at the top right of your screen. Please select another class or call 0800 865 432 or email info@cancersupport.org.nz

Please fill in your details for all the fields marked * to enable your registration to be completed. You do not need to be referred to register for a class. If you need any help completing your registration please call 0800 865 432.

Contact Details

First Name

Last Name

This will be used to send class details, so please make sure it is the Contact's email address. If you don't have an email please call 0800 865 432

Mobile Phone

02XXXXXXXXX

Street No and Address

City

Region

Postcode

How did you hear about us?

Which best describes you?

Volunteer Role

Where are you in your treatment journey?

What type of cancer are you being treated for?

Is this your FIRST time registering for our classes?

Registration Details

Date of Birth

dd/mm/yyyy

Gender

Ethnicity

We like to thank the wonderful people who share our services. If you were referred by someone (e.g. a health professional, workplace, charity or other organisation) please let us know. If not, please feel free to leave this section as blank.

Referrer Organisation Name

If unknown, leave blank

Referrer Email

If unknown, leave blank

Community Registration

Any special requirements eg wheelchair access?

Would you like to bring a Support Person?

Support Person Name & Contact Details (Mobile/Email)

Pack Registration Details

The following information assists us in providing the best products to suit you. Please complete all categories

Please be aware that cosmetic, makeup and skincare products are provided and used in our classes. Our programmes are non-medical — participants should consult their oncologist if they have any concerns about the products we use. A list of donated brands is available on our website. Please read our Privacy Policy for more information on how we use your information

Are there any products/brands that you should not use for health or medical reasons (including reasons related to your treatment)?

Preferred Lipstick Shade

Eyebrow Colour

Skin Tone

Are there any questions you would like to submit to be answered during the Q&A ?

Thank you for taking the time to provide us with information that will help us ensure you get the most out of your experience.

If you have any questions please call 0800 865 432