Completing This Survey

Enables You to Receive Newsletters and

You will be Considered a Member.

No Membership Fee is Required.

C-PAG, Inc.

Cancer Patients Advocacy Group

c/o Phil Zampino

2415 Bevington St. NW

Canton, Ohio 44709-2221

Phone: 330-493-6661

General Information About Cancer: http://www.GabrailCancerCenter.com/

C-PAG News Articles and CD Cover (Cancer Is On My Mind)

You Are Viewing This Page ***C-PAG Survey: C-PAG Survey.htm

C-PAG Mission Statement: C-PAG.htm

C-PAG Gathering Information: C-PAG Calendar.htm

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Email: CancerPAG@aol.com

C-PAG Survey

My name is Phil Zampino (Profile of Phil Zampino) and I have cancer. I have spoken with other cancer patients about organizing a Cancer Support Group called C-PAG. This will be a Support Group operated and run by its own participants [the cancer patients, their families and caregivers]. We have a sponsor [Gabrail Cancer Center and Research] who is willing to support us by supplying us with a meeting place, some financial help and logistics. This SURVEY will enable us to determine the two most important issues, a) meeting frequency, and b) type of programs that WE want or need. Hopefully, we will be able to attract professionals in the cancer field so that they address your questions, and so that you are better informed about your cancer.

Your input, wants and needs are extremely important during this organizing process. Please take a few minutes to complete this survey and please mail it back to the address at the top of this page.

1. Are you interested in belonging to a Cancer Support Group?			Yes	No
2. Would you like family members be invited to attend?			Yes	No
3. Would you need transportation to and from the meetings?			Yes	No
4. What day(s) of the week would you most likely be able to attend a meeting?	Monday	Tuesday	Wednesday	Thursday
5. How often would you like to have meetings?		Weekly	2x Monthly	Monthly

Please list your wants and/or needs that would help you benefit from this group. (Example 1: I would like to see the large group broken down into smaller groups with the same type of cancer for 10 minutes of each meeting. Example 2: I would like us to spend time on prayer and spirituality.)

6-a: __________________________________________________________________________________

6-b: __________________________________________________________________________________

6-c: __________________________________________________________________________________

Your Name: ____________________________________________________________

Street/Mailing Address: __________________________________________________

City: ___________________ State: ___________ Zip Code: _____________________

Email: _____________________________ Phone: (______)______________________

Oncologist: ______________________________________________________________

Type of Cancer: ____________________________________ Date Diagnosed: __/__/__

How would you prefer to be contacted?		Mail	Email	Phone
How did you hear about C-PAG?	Doctors Office Other:	Hospital	Newspaper	Mailer
Would you like to help on one of the committees?			Yes	No

If yes, please indicate all of the below that apply.

Committees

Meeting Facilitator	Monthly Program	Spirituality/Patient Relations
Transportation	Refreshments	Marketing/Media
Newsletter/Postal Mailing	Fundraising	Survey Results Projects
Planning Activities/Exercise	Email	Phone Calling/Attendance
Correspondence	Hospital & Home Visiting	Budget
Legal	Historian	Informational Catalogs

Additional Comments and/or Suggestions:

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________

Please return this form by mailing it to the address at the top of this page.

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Email: CancerPAG@aol.com

C-PAG, Inc.

Cancer Patients Advocacy Group

2415 Bevington St. NW - Canton, Ohio 44709 - Phone or Fax: 330-493-6661

Gathering & General Information

http://www.GabrailCancerCenter.com/ or http://www.PAZPublishing.com/C-PAG.htm

C-PAG, Inc. is Officially & Legally a Tax-Deductible, Non-Profit Organization!

The State of Ohio (#1460285) and the Federal Government (IRS) (FIN: #20 1495486) approved

C-PAG, Inc. (DLN: 304348038) to become a Tax-Exempt Non-Profit Organization,

with a Public Charity Status: 170 (b) (1) (A) (vi)

Donation Form

YES! I want to help C-PAG, Inc. become the Cancer Support Group

of Northeast Ohio that will provide patients and survivors, caregivers and

family members information, guidance and a better understanding of living

through cancer and give them the support they want and/or need.

C-PAG, Inc. would appreciate your contribution gift.

Enclosed is my tax-deductible gift of:

___$5 ___$10 ___$15 ___$20 ___$25 ___$50

$______ Other

Please print two (2) copies of this Donation Form.

One (1) copy mailed to C-PAG, Inc. with your check to:

C-PAG, Inc. - 2415 Bevington St. NW - Canton, Ohio 44709

One (1) copy will represent your tax-deductible certificate receipt.

Thanking you in advance for your Support of

cancer patients and survivors, caregivers and family members,

May God's Blessings and Good Health be with You and Yours,

Phillip Zampino

Founder & President of C-PAG

Donate $10 or more and receive a copy of this CD.

All Profits will benefit C-PAG, Inc. (Cancer Patients Advocacy Group)

a nonprofit tax-exempt organization.

Inspiring Songs! Uplifting Songs! Memorable Songs!

Sing-A-Long with the Songs (The words are provided)

Cancer We've Survived (Vocal)

Jubilation! Celebration! (Vocal)

Cancer Is On My Mind (Vocal)

Lord Help Us Be Cancer Free (Vocal)

Cancer We've Survived (Instrumental)

Jubilation! Celebration! (Instrumental)

Cancer Is On My Mind (Instrumental)

Lord Help Us Be Cancer Free (Instrumental)

If you donated $10 or more, would you like a copy of the above-pictured CD?

YES _____NO _____

C-PAG, Inc. Officer's President Phil Zampino - 493-6661 Vice-President Greg Walker - 644-3186 Secretary/Treasurer Diana Gray-Stromsky - 491-1191 If you would like to be on one of our committee's please let us know. We would love to have YOU! Committee's
Facilitator Diana Gray-Stromsky - 491-1191 Spirituality/1 on 1 Counseling/ Patient Relations Mary Lamielle - 477-9132 Greg Walker - 644-3186 Phone Calling/Attendance Anita Elliott - 455-5943 Fund Raising Phil Zampino Jennifer Collins (Breast Cancer Birds Art Gallery) Monthly Program Executive Officer’s Spirituality Committee Hospital & Home Visiting Mary Lamielle - 477-9132 (Spirituality Committee) Greg Walker - 644-3186 Transportation Ron Brinkman - 308-5525 Greg Walker - 644-3186 Budget Mary Rohr - 823-8961 Historian/Research/Informational Catalogs Executive Officer’s	Correspondence Diana Gray-Stromsky - 491-1191 Refreshments Jessica & Jean Kinsinger Ruth Alpago - 875-9954 Lynn Farina-Cowles - 866-3087 Sherry Kiko - 837-2451 Debra Darr - 882-4434 Media/Marketing Phil Zampino Newsletter/Postal Mailing Debra Darr - 882-4434 Anita Elliott - 455-5943 Phil Zampino Emailing Phil Zampino Anita Elliott Planning Activities and Exercise Julie Risher - 456-5737 Phil Zampino Survey Projects Greg Walker - 644-3186 Legal Attorney, Andy Ginella - 492-4249 Paralegal, Deana Zampino-Stafford - 492-4249
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