Faith Strong, Inc. Participant Agreement

Faith Strong, Inc. Participant Agreement
I. Privacy Notice

Faith Strong collects information in support of our mission to provide emotional, spiritual and relational support to women affected by breast cancer through the services we offer. The information you provide allows us to personalize your interactions with Faith Strong so that we can better serve you emotionally, spiritually and relationally and provide you with resources you may need. Occasionally, Faith Strong, Inc. will apply for grants to help with our services, such as providing gas cards and gift cards for meals and groceries when funds are available. In addition, Faith Strong has sponsors along with churches, organizations, and businesses who often donate items to Faith Strong to be distributed among its members/BREASTies. Faith Strong will only service, communicate with, and distribute donations to individuals who complete and sign the below Acknowledgment and Consent.
II. Contact & Database Information For Participant
Name*

First NameLast Name
Cell Phone*
Please enter a valid phone number.
Home Phone
Please enter a valid phone number.
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*

MonthDayYear
Date
Age*
Marital Status*

SingleMarriedDivorceWidowOther
Are you a single parent of a child under the age of 18?*

YesNo
I am a Breast Cancer:*

SurvivorThriver (actively in Treatment)METAvivor (Stage IV)Other
Year of Diagnosis*
Stage of Diagnosis*
Type of Breast Cancer*
What's your favorite color?
What's your favorite Holiday?
What's your favorite season?
Tell us something fun about you or any information you would like to share.
III. Acknowledge & Consent
IInsert your first and last name*, authorize Faith Strong to use and share my above information for the following purpose(s):

Initial* Monthly support group communications, events and activities

* Monthly Love Mail communications via U.S. Mail (including birthday acknowledgment)

* Grant funding for Faith Strong and Faith Strong services

* Resources and additional services for women affected by breast cancer

*Goods and services donated to Faith Strong for distribution

*Faith Strong Angels services (this service is provided only to BREASTies who are actively receiving any type of Breast Cancer Treatment, such as chemotherapy, immunotherapy radiation, surgery, or stem cell, or are diagnosed as Stage IV. Your information will be shared with an anonymous citizen of the United States who will be assigned to you for one year with a commitment of a monthly contact via U.S. Mail of greeting cards, notes of encouragement, care package, etc.)
By signing below, I consent to Faith Strong using my personal data for the purpose(s) indicated in this notice and understand that I can withdraw my consent at any time.
Insert Your Name*
Please Sign*

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Date*

MonthDayYear
Date
To inform Faith Strong of any desired restrictions or to make changes at any time, email us at info@wearefaithstrong.com or mail your request to

Faith Strong, Inc.

PO Box 3398, Sumter, SC 29151-3398
Optional Questions

This information is not public and will only be used to apply for grants and other funding opportunities. However, it will NOT be connected to your demographics.
What is your ethinicity?

Black or African American.WhiteHispanic or LatinoAmerican Indian or Alaska NativeAsianNative Hawaiian or Other Pacific Islander
What is your employment status?

Employed Full TimeEmployed Part TimeUnemployed and job seekingUnemployed awaiting disabilityDisabledOther
Do you have access to transportation (Car Owner, Personal Driver, etc.)?

YesNoOther
Are you receivign any public assistance (Food Stamps, Medicaid, Workfirst, Child Care Subsidy, Housing Authority, etc.)?

YesNo
Should be Empty: