Make an Impact Volunteer Form


The Memorial Sloan Kettering Make-an-IMPACT initiative provides individuals with rare cancers the opportunity to receive genomic testing at no cost to the patient. The primary purpose of the Make-an-IMPACT initiative is to understand why these rare cancers occur and to accelerate the development of new therapies for these diseases. This completed form will be submitted to our Make-an-IMPACT team. You should expect an email from the Make an IMPACT team ([email protected]).

Your phone number must be entered using the XXX-XXX-XXXX format.
Are you providing information about the cancer diagnosis and treatment of [check one]
Please enter in this format MM/DD/YYYY
Did you undergo surgery for your cancer?
Has chemotherapy been administered?
Are you (or is the patient about whom you are providing information) cancer free?