[../../includes/header.htm]

 

 

Registered Angels, click here to go to Angel's Corner...

You can make a difference!

Your support is urgently needed. Help us continue to bring a ray of sunshine to those battling cancer...

DONATE HERE...

 

 

 

 

 

Send this site to a friend! (click here)

 

Chemo Angels
P.O. Box 1971
Julian, CA 92036

USA

E-mail us...
 

 

 

 
Patient Sign-up Form for Women
 
Full Name:
Nickname/Goes By:
Address:  
City, State, Zip:  
Country:
   
Telephone No:  
E-mail address:  
   
Your Birthday:
Age:  
   
How did you hear about Chemo Angels:  
   
Date your treatment starts/started:
   
Estimated end of  treatment date:
   
Type of cancer:
   
Type of treatment:  
   
Stage of cancer:
   
Provide complete Name & Address of your Oncologist  
   
Any other relevant health information
   
Briefly tell us about you and describe the Hobbies/Activities you enjoy:
   
Tell us about your favorite (mailable) snacks and treats:
   
Do you have any dietary restrictions or allergies:
   
What is your favorite type of tea/coffee:
   
What kind of music to you like:
   
What books/magazines to you read:
   
Favorite animal or animals:
   
Favorite flower(s):
   
Favorite color(s):
   
Favorite candle scent(s):
   
What is your T-Shirt size:
   
   

Tell us about the books you read:   popular fiction   mysteries/thrillers   action/adventure   science fiction/fantasy   biographies     comedy/humor   horror   true crime   sports   religion/spiritual   classics   history     non-fiction

Do you enjoy:   candles   incense   potpourri   sachets         body sprays   scented soaps   body lotion   bath salts   angels     bubble bath     shower gel

Do you enjoy:   crossword puzzles   stationary/note cards   magnets   word search

Do your wear pierced earrings?   yes

What is you preference in fragrance?   fruity scents   floral scents   fresh scents

Do you prefer...   VHS (video tapes) or DVD's?   VHS      DVD's     

Cassette tapes or CD's?   cassettes      CD's

Do you celebrate:   Christmas   Hanukah   other...specify  

 

If religion/spirituality is important in your life, please tell us what religion you are or briefly describe your spiritual beliefs:

no religious/spiritual encouragement, please  

 

If you are married or have a significant other, tell us about their name, age, birthday, interests, etc:

If you have children or grandchildren who live in your home, tell us about them, list names, genders, birthdays and ages, interests, hobbies, etc:

If there is anything else you can think of... things you collect, things that cheer you up, things you like to do, etc...please indicate so in the following space. Any further information you can give us as to your likes and dislikes would be greatly appreciated by our program. Thank you!

 

Check-Ins
Your only obligation as a recipient of our program is to respond to the check-ins that we will send you each month. Your regular monthly feedback is vital to the success of our program. If we do not hear from you in response to a monthly check-in, we will try to get in touch with your contact person. If we are unable to reach both, you and your contact person for more than two consecutive months, we will have to remove you from the program.   yes, I understand the importance of responding to the monthly check-ins in a timely and informative manner, and will do my best to comply.

 

Contact Person
Chemo Angels administration needs a contact person, a close friend or relative who generally knows what is going on in your life. This person must have an  e-mail address and a postal address  different than yours. No spouses, please.
Contact Persons Full Name:
   
Contact Persons e-mail address:  
   
Contact Persons postal address:  
   
Relationship to applicant:
   

 

There are times when some extra attention and encouragement may be helpful. During such a time we have "Special Assignment Angels" who send cards, letters of support, and perhaps a small gift to those in need of some extra cheer. If you do not wish to have your address given to the Special Assignment Angels at any time, please indicate so below. Regardless of which option you choose, your address and information will never be given to anyone outside our organization.

yes, if needed, I would love to be a recipient of a Special Assignment

no Special Assignment please. Only give out my address to my assigned Angels.

 

If you are submitting this application for someone else, please give the following information about yourself. Thank you!

Your name:
   
Your e-mail address:
   
Your relationship to applicant:
   

 

 

 

 

 

  

 

 
   

[../../includes/footer.htm]