Note: Fields marked with red asterisk are required.

Personal Information
The email address is not made public. It will only be used if you need to be contacted about your account or for opted-in notifications.
Several special characters are allowed, including space, period (.), hyphen (-), apostrophe ('), underscore (_), and the @ sign.
Member Name
Address 1
Address 2
Phone 1
Phone 2
Cell Phone
Medical History
Before Proton Therapy, have you ever been treated for prostate cancer?
Proton Therapy Information (check all that apply)
Are you receiving the standard treatment protocol?
Estimate if you aren’t sure
Estimate if you aren’t sure
Estimate if you aren’t sure
Enter a number here only if you have completed treatment.
Enter "none" if you do not have insurance or are having problems with insurance.
Depending on the issue, we may be able to offer advice.
Important: Please provide the name(s) of individual(s) who informed you about proton therapy and/or former proton therapy patients you communicated with prior to making your treatment decision. If you don't remember name(s), enter "Forget." If you learned about proton therapy on your own, enter "Self."
Are you willing to share your experience with non-members?
Would it be O.K. for BOB to use the information you provided on this registration form in order to be able to assist individuals (non-members) who are evaluating proton therapy and would like to speak with someone with similar conditions as theirs?

By selecting ‘No’, your information will not be shared by BOB with non-members who are evaluating proton therapy. However, your information will still be used by BOB to enable communication between BOB members. If you do not want your information to be shared with anyone please do not register as a member.
Giving Back Participation
Periodically we share information with BOB members about proton research and other programs underway at Loma Linda University Health. If you do not wish to hear about these programs or participate in supporting them please let us know by checking the corresponding box below.
By selecting the ‘Accept’ button below, I acknowledge that I am voluntarily applying for membership at the Brotherhood of the Balloon (BOB) prostate cancer support group and providing my personal information to be used according to BOB’s Terms and Conditions of Use Policy. I understand that my application will be reviewed and that I may be contacted for additional clarification prior being accepted as a member. I understand that as a member, I may become aware of other members’ personal information and will treat that information with care and will not share it with anyone else unless the owner of the information specifically authorizes me to do so. I understand that the information I have provided on this registration form may be shared with other BOB members according to the Terms and Conditions of Use Policy. I also agree to make myself available to be contacted by other BOB members in order to share my personal experience with proton therapy. I further understand that any disclosure of information carries with it the potential for an unauthorized redisclosure, therefore it is up to me to decide what additional personal information I want to share with other BOB members when contacted by them.