H.A.L.O Profile Form

H.A.L.O. PROGRAM

H.A.L.O (Healed Angels Living On) is a sisterhood Program, dedicated to Young survivors, caretakers, and guardian angels (aged 20-50).It consists of 5 programs that will serve this Young group of women mentally, spiritually, physically, and emotionally. It is also dedicated to Young Women's EMPOWERMENT.

The Program Includes

Mental Health Mondays | Her G.L.O.W (Growing, Living, Overcoming & Winning) This program will help Young women gain control of their mental health.

Spiritual Awakening Sundays | Her L.I.G.H.T (Lives Influenced by God's Holy Teachings) Program is devoted to helping Young women grow in their Spiritual journey.

Fitness Friday | Her FIRE Program will inspire Young women to get their body moving.

Monthly Meetups | She S.H.I.N.E.S (Sisters Healing In Everyday Sunshine) Program is devoted to emotional wellness. This program will allow us to do things such as Bowling, Paint and Sips, Wine Tastings, Lunches, Dinners, and more.

Educational Empowerment | EMPOHER Program is commited to Empowering Young women through Quarterly Empowerment Meetings. These meetings will include topics such as Advocacy, Self-care, Skin-care, Nutrition, Finances, Resources and more.

Membership Requirements

Complete and submit this membership profile form

If you wish to just be on committee please go to website and fill out Committee form.

Participate in as many events and activities that will serve you in the season you

Today's Date:*

Date

Are you already a member of Angel's Surviving Cancer, Inc*

YesNo

Are you a guardian angel (non survivor

YesNo

Name:*

First NameLast Name

Birth Date*

MonthDayYear

Age*

Phone Number:*

Area CodePhone Number

E-mail Address:*

Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Race/Ethnicity: *

Your Education:*

Currently Employed? If yes, name and address of current employer*

Marital Status:*

SingleMarriedDivorced/SeperatedWidowed

Do you have children?*

If yes, how many? (We will involve the children in some of our future activities)

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Emergency Contact Relationship*

Are you on Facebook*

YesNo

Are you on Instagram*

YesNo

If yes, what is your @handle?*

Put N/A if you are not on Instagram

HISTORY

Below are a few questions about your history. Please take your time and answer each question to the best of your ability

Do you have a family history of breast cancer?*

If yes, who?*

Have you ever had a previous breast biopsy?*

Diagnosis If you are a Guardian Angel (non suvivior) skip down to the end of form

Below are a few questions about your diagnosis. Please take your time and answer each question to the best of your ability

Date of diagnosis, if diagnosed:

Please Leave blank if you were never diagnosed or you 'have not/don't plan to take chemotherapy

How was the mass/lump detected?*

Before diagnosis, were you doing any of the following? Select all that apply:*

Age at diagnosis:*

Put 0 if you were never diagnosed

Which breast*

N/ALeftRightBoth

Stage & Type of Cancer?*

Put N/A if you were never diagnosed

Do you have you pathology report?*

Put N/A if you were never diagnosed

Treatment

Below are a few questions about your past/present treatment. Please take your time and answer each question to the best of your ability

Do you currently have insurance?*

Select N/A if you were never diagnosed

Are you currently in treatment?*

Select N/A if you were never diagnosed

Chemotherapy Therapy:*

N/AYesNo

When did/will you start Chemotherapy:*

Please Leave blank if you were never diagnosed or you 'have not/don't plan to take chemotherapy

Where are you receiving Chemotherapy?*

Put N/A if you were never diagnosed or you have not/don't plan to take chemotherapy

Type of Chemotherapy:*

Put N/A if you were never diagnosed or you have not/don't plan to take chemotherapy

Results/Outcome:*

Put N/A if you were never diagnosed or you have not/don't plan to take chemotherapy

Radiation Therapy*

N/AYesNo

When did/will you start Radiation Therapy:

Leave blank if you were never diagnosed or you 'have not/don't plan to take radiation therapy

Where are you receiving radiation?*

Put N/A if you were never diagnosed or you have not/don't plan to take radiation therapy

Results/Outcome:*

Put N/A if you were never diagnosed or you have not/don't plan to take radiation therapy

Surgery Options:*

Date of Surgery

Leave blank if you were never diagnosed or you 'have not/don't plan to have surgery

Where are you receiving surgery?*

Put N/A if you were never diagnosed or you 'have not/don't plan to have surgery

Results/Outcome*

Put N/A if you were never diagnosed or you 'have not/don't plan to have surgery

Do you wear prosthetics?*

Put N/A if you were never diagnosed or you 'have not/don't plan to have surgery

Are you considering reconstruction?*

N/AYesNo

Any Recurrence(s)?*

Put N/A if you were never diagnosed

Please tell us which program/programs you are most excited about within the H.A.L.O Program*

Name of person who referred you:

First NameLast Name

The Annual Dues for membership is $50.00 Please submit your payment visit our site at www.angelssurvivingcancer.org If you have any questions or concerns, Please contact 281-912-5195 and I will be more than happy to assist you. angelssurvivingcancer.org

Volunteer for committees no annual fee

If you are in need of a free wig, Please contact Beauty Beyond Breast Cancer- Venita Graves at 832-372-4247. Please let her know Angel's referred you. (By appointment only)

If you currently do not have insurance or medicare, please contact Tricia Garmond with MD Anderson at 713-792-4322