GPS Register - St. Christopher Truckers Development and Relief Fund

Name

First

Last

Cell Phone

Email

Age

Gender

Are You a Class A Semi-Truck Driver?

Please Upload a Copy of CDL

Drag & Drop Files, Choose Files to Upload

Please enter your address:

Address Line 1

Address Line 2

City

State

Zip Code

Which Best Describes Your Route:

Which type of test would you like?

Which type of test would you like?

***PLEASE NOTE*** Prostate screenings are ONLY available for men ages 50-69, unless there is a close family history.

***PLEASE NOTE*** Cervical cancer screenings are ONLY available for women ages 30-65.

Is there a close family history (father or brother) of prostate cancer in your family?

Do you have health insurance?

How did you hear about the GPS Program?

Questions or comments?

By checking this box, you are agreeing to provide the St. Christopher Fund with results from your preventative cancer screenings.

For prostate cancer screening only:

By checking this box, I acknowledge that the St. Christopher Fund will create an account on my behalf through Call on Doc for the purpose of requesting a test kit, providing results, and referral to resources if results are positive.

For cervical cancer screening only:

By checking this box, I acknowledge that the St. Christopher Fund will create an account on my behalf through MyLAB Box for the purpose of requesting a test kit, providing results, and follow-up if results are positive.

Register Today for Your Free Kit