Your data "*" indicates required fields FIRST NAME* LAST NAME* EMAIL* DOB* Day Month Year GENDER*GENDERManWomanGender QueerNon-BinaryOtherARE YOU TRANS?*ARE YOU TRANS?YesNoUnsurePrefer not to sayGENDER ASSIGNED AT BIRTH*GENDER ASSIGNED AT BIRTHMaleFemaleIntersexPrefer Not To SayWe are asking this only to ascertain the gendered reproductive organs you may have in relation to a cancer diagnosis. this is purely for our research purposes and will remain anonymous - promiseSEXUAL ORIENTATION*SEXUAL ORIENTATIONStraightGay / LesbianBi-curiousBiAsexualPansexualDemisexualFluidQueerSapiosexualUnsurePrefer not to sayETHNICITY*ETHNICITYWhite English, Welsh, Scottish, Northern Irish or BritishWhite IrishWhite Gypsy or Irish TravellerAny other White backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or Multiple ethnic backgroundIndianPakistaniBangladeshiChineseAny other Asian backgroundBlack AfricanBlack CaribbeanAny other Black, African or Caribbean backgroundArabAny other ethnic groupRELIGION*RELIGIONAtheistAgnosticSpiritualChristianBuddhistHinduJewishMuslimSikhOtherCOUNTY OF RESIDENCE*COUNTY OF RESIDENCEBedfordshireBerkshireBristolBuckinghamshireCambridgeshireCheshireCity of LondonCornwallCumbriaDerbyshireDevonDorsetDurham (County Durham)East SussexEssexGloucestershireGreater LondonGreater ManchesterHampshireHerefordshireHertfordshireIsle of WightKentLancashireLeicestershireLincolnshireMerseysideNorfolkNorth YorkshireNorthamptonshireNorthumberlandNottinghamshireOxfordshireRutlandShropshireSomersetSouth YorkshireStaffordshireSuffolkSurreyTyne and WearWarwickshireWest MidlandsWest SussexWest YorkshireWiltshireWorcestershireYorkshire, East RidingCity of AberdeenAberdeenshireAngus (Forfarshire)ArgyllAyrshireBanffshireBerwickshireButeCaithnessClackmannanshireDumfriesshireDunbartonshire (Dumbarton)City of DundeeEast Lothian (Haddingtonshire)City of EdinburghFifeCity of GlasgowInverness-shireKincardineshireKinross-shireKirkcudbrightshireLanarkshireMidlothian (County of Edinburgh)Moray (Elginshire)NairnshireOrkneyPeeblesshirePerthshireRenfrewshireRoss and CromartyRoxburghshireSelkirkshireShetland (Zetland)StirlingshireSutherlandWest Lothian (Linlithgowshire)WigtownshireBlaenau GwentBridgend (Pen-y-bont ar Ogwr)Caerphilly (Caerffili)Cardiff (Caerdydd)Carmarthenshire (Sir Gaerfyrddin)CeredigionConwyDenbighshire (Sir Ddinbych)Flintshire (Sir y Fflint)GwyneddIsle of Anglesey (Ynys Môn)Merthyr Tydfil (Merthyr Tudful)Monmouthshire (Sir Fynwy)Neath Port Talbot (Castell-nedd Port Talbot)Newport (Casnewydd)Pembrokeshire (Sir Benfro)PowysRhondda Cynon TafSwansea (Abertawe)Torfaen (Tor-faen)Vale of Glamorgan (Bro Morgannwg)Wrexham (Wrecsam)AntrimArmaghCity of BelfastDownFermanaghLondonderryCity of DerryTyroneEuropeAsiaAustraliaAfricaNorth AmericaSouth AmericaEMPLOYMENT STATUS*EMPLOYMENT STATUSEmployed - Full TimeEmployed - Part TimeSelf-Employed - Full TimeSelf-Employed - Part TimeUnemployedUnable To WorkVolunteerRetiredOCCUPATION*OCCUPATIONAgriculture; plantations;other rural sectorsBasic Metal ProductionChemical industriesCommerceConstructionEducationFinancial services; professional servicesFood; drink; tobaccoForestry; wood; pulp and paperHealth servicesHotels; tourism; cateringMining (coal; other mining)Mechanical and electrical engineeringMedia; culture; graphicalOil and gas production; oil refiningPostal and telecommunications servicesPublic serviceShipping; ports; fisheries; inland waterwaysTextiles; clothing; leather; footwearTransport (including civil aviation; railways; road transport)Transport equipment manufacturingUtilities (water; gas; electricity)MARITAL STATUS*MARITAL STATUSSingleDatingIn a RelationshipIt's ComplicatedCohabitingEngagedMarriedSeperatedDivorcedWidowedCHILDREN?*CHILDREN?YesNoUndecidedUnable to have childrenARE YOU...*ARE YOU...A cancer patientLiving beyond cancerLiving with stage 4 cancerFamily member of someone affected by cancerFriend of someone affected by cancerCarer of someone affected by cancerMedical professional - oncologyMedical professional - other (please state)Charity / not-for-profit that supports those affected by cancerHad cancer scareOther (please state)HOW WOULD YOU LIKE TO IMPACT CHANGE? Share your story publically Share your story anonymously Take part in focus groups - anonymous Take part in online surveys - anonymous Take part in girlvscancer campaigns Be put forward for relevant third party research Be put forward for relevant third party campaigns Be involved in policy change campaigns & processes Select AllWOULD YOU LIKE TO HEAR FROM GIRLvsCANCER?*WOULD YOU LIKE TO HEAR FROM GIRLvsCANCER?YesNoNot Sure YetHOW WOULD YOU LIKE TO HEAR FROM GIRLvsCANCER? General Updates & Announcements Useful Resources & Information Product Launches & Collaborations Community Stories & News Campaigns & How To Get Involved For Research Participation Purposes Only Select AllTerms and conditions* By ticking this box I can confirm I have read and accept the terms and conditions.
