Positively Pink Hearts for the Holidays
The Positively Pink Foundation, Inc. is honored to support mothers currently undergoing breast cancer treatment. Please complete the information below to help us ensure your family receives holiday assistance and event details.
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TO DONATE & SUPPORT A MOM FOR THE HOLIDAYS!
Section 1: About You
Name
First Name
Last Name
Mobile Phone:
Do you wish to be included on event updates via text?
Yes, please
No thank you
Email Address:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How do you prefer to be contacted?
Call
Email
Text
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Section 2: Your Breast Cancer Journey
What is your current status?
In active treatment
Recently underwent treatment (within 2 years)
Long-term survivor (more than 2 years post-treatment)
Types of Treatment (check all that apply)
Chemotherapy
Radiation
Surgical procedure
Hormone therapy
Other
Treatment Center/Hospital Name, City and State (optional)
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Section 3: Children & Holiday Support
Are you a mother or primary caregiver to any children under 18?
*
Yes
No
Tell us more about your children (age, male/female & any special needs)
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Section 4: Event Attendee Details
Will you attend the Positively Pink Holiday Dinner on December 11 at 6:30pm?
Yes
No
Unsure
If attending, will you be attending:
By myself
With a plus one
Please indicate any dietary needs/restrictions or allergies
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Section 5: Photo & Media Consent
Do you give permission to be photographed or recorded during the event?
Yes, I grant consent
No, I do not grant consent
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Section 6: Communication Consent
Would you like to receive updates about The Positively Pink Foundation's programs and future events?
Yes
No
Preferred method of contact
Text
Email
Both
Submit
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