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Thank you for taking time to take part in this survey. National blood cancer charity Cure Leukaemia began funding specialist research nurses at 12 blood cancer centres across the UK in January 2020 and a Hub in Birmingham to form the Trials Acceleration Programme (TAP).

TAP enables blood cancer patients from a catchment area of 20 million people to access potentially life saving treatments for all forms of blood cancer through clinical trials. Without TAP and the nurses Cure Leukaemia funds, these trials would not run and patients would miss out on potentially life saving treatments.

By sharing your story with Cure Leukaemia you are helping to raise awareness of the importance of TAP and encouraging businesses and individuals across the UK to raise funds for Cure Leukaemia to benefit patients now and in the future. The 20 minutes you spend filling this in could make a huge impact whether that be through providing a story for a Trust or Foundation application, striking a chord with a local business that subsequently decides to support Cure Leukaemia or touching an individual who then decides to raise funds for the charity. Click here for an example of a previous story we have featured and this inspiring story of an ALL survivor who went on to become a haematology nurse click here.

We are immensely grateful to you for taking the time to share your story and we can assure you that anything you write will be treated sensitively and will not be used publicly without your express permission.

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* 1. First Name

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* 2. Surname

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* 3. Email address

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* 4. Phone number

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* 5. Postal address

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* 6. Twitter handle (if applicable)

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* 7. Instagram handle (if applicable)

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* 8. What is your date of birth?

Date

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* 9. What is your occupation?

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* 10. Please let us know the company you work for (if applicable)

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* 11. Let us know your interests

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* 12. Type of blood cancer you had or have?

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* 13. Your age and the year you were diagnosed

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* 14. The hospital you were or are treated at

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* 15. Name of your principle consultant

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* 16. Did you or will you take part in a clinical trial for your treatment?

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* 17. Did you or will you require a transplant?

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* 18. Please share your story here. Please go into as much detail as you would like. If you fill this in and share this information with Cure Leukaemia you agree to allow us to share this story publicly on social media and, in some cases, Cure Leukaemia may ask you if you are happy for this to be sent to the media. If you are unsure about this please do email Gemma@cureleukaemia.co.uk for further clarification.
Note that nothing would be shared publicly without your final sign off and approval.

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* 19. Please share a primary photo of yourself that you would be happy for Cure Leukaemia to use alongside your story.

PNG, JPG, JPEG, GIF file types only.
Choose File

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* 20. Please share an additional photo - it is always preferable to have a number of photos for your story

PNG, JPG, JPEG, GIF file types only.
Choose File

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* 21. Please share an additional photo - it is always preferable to have a number of photos for your story

PNG, JPG, JPEG, GIF file types only.
Choose File

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* 22. Please share an additional photo - it is always preferable to have a number of photos for your story

PNG, JPG, JPEG, GIF file types only.
Choose File

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* 23. How would you prefer Cure Leukaemia contacted you in the future? Tick all that apply

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* 24. Personal Declaration

By submitting this form and after viewing Cure Leukaemia's Privacy Policy I am happy to be contacted via the communication methods stated above.

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