S.T.E.P. Application

Name*
First Last
Email
Phone
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Employment/School Name*
Employment/School Status
Relationship to Person Diagnosed with Cancer*
Date of Last Active Treatment?
Note from Doctor
Drop files here or

Accepted file types: jpg, png, pdf, docx, Max. file size: 400 MB.
Cancer Survivors’ please upload a note from your doctor stating that you are cleared for physical activity and please include any and all limitations. All others please upload proof of active cancer treatment or treatment in the last 2 years of cancer patient selected above.
Do You Play Sports?*
Hidden
List Sports Played
How Did You Hear About this Program?*
What are Your Fitness Goals?*

Cancer Survivors’ please upload a note from your doctor stating that you are cleared for physical activity and please include any and all limitations. All others please upload proof of active cancer treatment or treatment in the last 2 years of cancer patient selected above.