Guardian Angels Profile Form

Guardian Angel Profile

Thank you for considering to be a "Guardian Angel"

Guardian Angels are members of ASC

(non breast Cancer Survivior) that Supports Angels Surviving Cancer, Inc. with events and other needs Guardian Angels

Annual membership fee $50

The sole purpose of this form is to collect data specifically relating to members.

All information provided this form will be kept confidential and access to this information will be strictly regulated and monitored. Your data will be entered into the database under a membership number; your name will not be included.

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 $50.00 ($30.00 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.

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

Anything Below this Line is For Office Use Only:

Full Name of Angel who took the Call:

Is Follow-up Needed

Follow-up Date & Time: