Guardian Angels Profile Form

Guardian Angel Profile

Thank you for considering to be a "Guardian Angel"

GUARDIAN ANGEL – Supporter • Advocate • Sustainer
• Not a breast cancer survivor
• Pays Annual Dues
• Official Supporting Member
• Provides steady financial & volunteer support
• Encourages and stands beside survivors
• Helps sustain ASC programs and services

Annual membership fee $55

Do you desire to become a guardian angel member of ASC?*

YesNo

Today's Date:*

Date

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

Emergency Contact*

First NameLast Name

Emergency Contact Phone Number*

Area CodePhone Number

Emergency Contact Relationship*

Are you on Facebook*

YesNo

Facebook information

HISTORY

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

Why do you want to be a guardian angel?*

What skills can you assist

Assisting to raise donations and sponsorshipAssisting with eventsAngels Executive BoardOther

The Annual Dues for membership is $55.00 ($35.00 seniors 70 yrs. older)

You can also visit our site at www.angelssurvivingcancer.org to pay, If you have any questions or concerns, Please contact us directly at info@angelssurvivingcancer.org or 281-912-5195 and we will be more than happy to assist you.

Full Name of Angel who took the Call:

Is Follow-up Needed

Follow-up Date & Time: