H.A.L.O Profile Form

Angels Survivng Cancer, Inc. H.A.L.O. PROGRAM

H.A.L.O. Program

Healed Angels Live On

The H.A.L.O. Program is a compassionate outreach initiative of Angels Surviving Cancer, Inc. designed to uplift, encourage, and provide practical support to individuals and families affected by breast cancer. H.A.L.O. represents hope, healing, and the power of community standing together as young breast cancer survivors during life’s most challenging moments.

Our Purpose

The H.A.L.O. Program exists to ensure that no survivor or family feels alone in their journey. We focus on restoring dignity, providing encouragement, and offering meaningful assistance that improves quality of life during and after treatment.

What H.A.L.O. Provides

Emotional Support – Encouragement, prayer, and peer connection.
Resource Referrals – Guidance to community services and healthcare resources.
Wellness & Survivorship Encouragement – Tools and information that promote healthy living and recovery.
Acts of Kindness & Care Packages – Thoughtful gestures that remind individuals they are seen, valued, and supported.

Who We Serve

The H.A.L.O. Program serves breast cancer patients, survivors, and their families within our community who are seeking encouragement, connection, and supplemental support as they navigate treatment or survivorship. Meeting them where they are ages 18-50. A safe space.

Our Commitment

We are committed to compassion, confidentiality, and respect. Every interaction through the H.A.L.O. Program is grounded in empathy and the belief that hope can shine even in difficult seasons

How You Can Help

Community support makes H.A.L.O. possible. You can partner with us by:

Volunteering your time
Donating care items or funds
Sponsoring outreach activities
Sharing resources and awareness
Together, we can be a light of hope — a H.A.L.O. for those who need it most.

Membership Requirements

Complete and submit this membership profile form annual dues $55.00 on angelssurvivingcancer.org

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?*

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 $55.00 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