Beacon Interest

Who is completing this form?

Myself Parent/legal guardian Spouse/partner Other caregiver

Full name

Email address

Mobile phone number

US format; used for SMS + call

Preferred contact method

Phone call Text message Email

Best time to reach you

Morning Afternoon Evening Anytime

Date of birth

Derives age for eligibility.

Sex assigned at birth

Female Male Intersex Prefer not to say

Gender identity (optional)

Woman Man Non-binary Prefer to self-describe Prefer not to say

City and state

ZIP / postal code

Primary geo-match signal.

How far would you travel for a study?

Under 10 mi 10–25 mi 25–50 mi 50+ mi Remote/at-home only

Preferred language

English Spanish Other

Preferred language (other)

I agree to be contacted about future research opportunities that may fit me.

I agree to be contacted about future research opportunities.

I have read the privacy notice and understand my information is stored securely and I can opt out anytime.

I have read and accept the privacy notice.

Cancer type

Diagnosis status

Confirmed diagnosis Suspected/under workup No diagnosis

Cancer stage

0 I II III IV Not sure

Has it spread (metastatic)?

Yes No Not sure

Current treatment. Choose any.

Chemotherapy Radiation Immunotherapy Targeted therapy Surgery Hormone therapy Active surveillance None yet

Number of prior treatment lines

None 1 2 3+

Known biomarkers / mutations (optional)

How active are you day to day?

Fully active Restricted from strenuous Up >50% of the day Limited self-care

[Breast] Hormone receptor status

HR-positive HR-negative Triple-negative Don't know

[Breast] HER2 status

Positive Negative Don't know

[Breast] Menopausal status

Pre-menopausal Post-menopausal Not sure

[Lung] Type

Non-small cell (NSCLC) Small cell (SCLC) Not sure

[Prostate] Castration-resistant?

Yes No Not sure

[Blood] Specific type

AML ALL CLL CML Multiple myeloma Hodgkin lymphoma Non-Hodgkin lymphoma Other

Beacon Interest — Cancer