National Associate Membership Application

National Associate Membership Application

Thank you for applying to be an Associate Member of Sisters Network Inc. This form is open to breast cancer survivors—particularly in areas without an active affiliate chapter—and supporters of the breast cancer community.
Date*

MonthDayYear
Date
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Age*
I prefer to be contacted by*

EmailPhoneText
Are you a survivor?*

YesNo
Year diagnosed*
What type of cancer?*

DCISTNBCMBCHR-HER2+IDC
What stage?*

01234
Are you currently in treatment?*

YesNo
VOLUNTEER OPPORTUNITES
National Events

Stop the Silence 5k Walk/Run (every April)National Black Breast Cancer Summit (every October)Public Speaking (Serve as an ambassador for Sisters Network Inc. to speak about breast cancer survivorship to small/large groups (in-person/virtually)
Communications:

Public Speaking (Serve as an ambassador for Sisters Network Inc. to speak about breast cancer survivorship to small/large groups (in-person/virtually)Public RelationsSocial Media
Public Policy

SNI Center of Public Policy (State Policy Initiatives)
Thank you for supporting Sisters Network Inc.

9668 Westheimer Road, Ste. 200-132 Houston, TX 77063 866.781.1808 www.sistersnetworkinc.org infonet@sistersnetworkinc.org

Please allow 30 days for review and response.
Should be Empty: