Benefit Recipient Nomination Questionnaire
Name
First Name
Last Name
Phone Number
Email
example@example.com
Preferred contact method:
Please Select
Phone Call
Text Message
Email
Date Of Birth
/
Month
/
Day
Year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Chronic Illness or type of cancer
How long have you received treatment?
Do you have dependents?
If Yes, how many?
How can this benefit/fundraiser help you and your family? Please attach a paragraph or two.
Have you had any benefits or fundraisers in the last 6 months?
Please Select
Yes
No
If Yes, please explain type of benefit/fundraiser:
Do you have any benefits or fundraisers coming up in the next 6 months?
Please Select
Yes
No
If Yes, please explain type of benefit/fundraiser:
Do you have currently have a GO FUND ME?
Please Select
Yes
No
If Yes, please provide the name/title of the GO FUND ME page.
Date Submitted to Pink Ladies Helena
/
Month
/
Day
Year
Date
Submit
Should be Empty: