Sign-up Form 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 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 their own e-mail address, and a postal address different than yours.

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:

Patient Sign-up Form for Women