Restored Radiance Foundation Application
Thank you for your interest in the Restored Radiance Foundation. Our Radiance Recovery Program provides oncology-safe skincare products and educational resources to eligible individuals affected by cancer who are experiencing treatment-related skin concerns and financial hardship.
Applicant Information
Full Name
*
First Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
City
*
State
*
ZIP Code
*
County
Primary Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Method of Contact
*
Phone
Email
Text Message
Cancer History
Cancer Type
*
Current Status
*
Currently Receiving Treatment
Recently Completed Treatment (Within 12 Months)
Cancer Survivor (More Than 12 Months)
Treatments Received or Currently Receiving
*
Chemotherapy
Radiation Therapy
Immunotherapy
Targeted Therapy
Hormone Therapy
Surgery
Clinical Trial
Other
Treatments - Other
Approximate Treatment Dates - From
-
Month
-
Day
Year
Date
Approximate Treatment Dates - To
-
Month
-
Day
Year
Date
Would you like to share anything about your cancer journey?
Skin Concerns and Skincare
Current Skin Concerns
*
Severe Dryness
Sensitive Skin
Peeling
Redness
Burning
Itching
Acne
Rash
Flaking
Oily Skin
Discoloration
Swelling
Tenderness
Breakouts
Sun Sensitivity
Irritation
Other
Skin Concerns - Other
Please describe your skin concerns
*
Do you currently use skincare products?
*
Please Select
Yes
No
If yes, please list any products you currently use
Have you received skincare recommendations from a healthcare provider?
*
Please Select
Yes
No
Unsure
What are you seeking assistance with?
Skincare Products
Restorative Facial
Education
Unsure - I'd like guidance
Financial Need and Referral
Financial Need Indicators
*
Medical expenses have significantly affected my finances.
I have reduced work hours because of treatment.
I have lost income due to cancer treatment.
I receive income-based public assistance.
I cannot afford recommended skincare products.
I am experiencing other financial hardship
Please briefly describe your current situation
How did you hear about us?
*
Hospital
Cancer Center
Oncology Nurse
Social Worker
Physician
Support Group
Community Event
Website
Social Media
Other
How did you hear about us? - Other
Were you referred by a healthcare provider?
*
Please Select
Yes
No
If yes, provider name
Signature
Applicant Signature
*
Date / Signature Date
*
-
Month
-
Day
Year
Date
Submit Application
Submit Application
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