Betty's Brave and Beautiful Hearts

Betty's Brave & Beautiful Hearts Foundation is proud to partner with Kentucky CancerLink to bring you this care kit. We are a small, dedicated nonprofit, and every kit is lovingly customized based on the needs you shared with us on your request form. If an item you expected isn't in your box, it's because we tailored your kit to what you told us — so that our remaining inventory can go on to help another woman on her breast cancer journey.

IMPORTANT INFORMATION, PLEASE READ:
This form must be completed by the intended recipient and cannot be submitted by anyone else.

Thank you for trusting us with a part of your breast cancer journey. Betty’s Brave & Beautiful Hearts Foundation provides post-mastectomy care kits to women in Kentucky with love and care, in partnership with Kentucky CancerLink.

Mastectomy care kit requests must be submitted at least 7 days prior to mastectomy surgery to allow time for packing and shipping.

Requests made outside of these timeframes cannot be fulfilled due to shipping limitations and the intended use of the products within the kits. At this time Betty's Brave & Beautiful Hearts Foundation does not provide kits for lumpectomy, chemotherapy or radiation treatment. This form must be completed by the intended recipient and cannot be submitted by anyone else.

All for Betty,
Rebecca Baker (Betty's Daughter) & Madalyne Kinnett

Please sign below to confirm that you have read, understand, and agree to the care kit request guidelines above.

Name

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Are you currently a Kentucky Resident and requesting this box for yourself?

Our nonprofit is a 501(c)(3) that provides kits at no charge to Kentucky Residents only. For out-of-state kits, please direct to the "donate a box" page on our website here.

Date of Birth

Date

Address (No P.O. Boxes)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

County

Are you scheduled for a Mastectomy or a Lumpectomy?

Is your Mastectomy more than 7 days away?

When is your Mastectomy?

Must be more than 7 days away

Unfortunately due to the items in these boxes you must be receiving a mastectomy to qualify.

Unfortunately due to the items in these boxes your mastectomy must be more than 7 days away to receive a box.

Treatment Center/location?

Shirt Size

Kentucky CancerLink has a standing office in Lexington where care kits will be available. Would you like for your care kit to be mailed to your address, or would you prefer to pick it up?

Kentucky CancerLink is located at 860 Corporate Drive, Suite 103, Lexington KY 40503.

The office is open for care kit pickups Monday-Thursday 10am-3:30pm.

You must have this form fully filled out and submitted before coming to the office for your kit.

As a small nonprofit, we want to make sure every donated item is put to good use and that your kit includes the items that will be most helpful to you.

If you already have any of the items below please let us know and we will customize your kit based on your needs.

Do you already have a Mastectomy Pillow?

Do you already have a Seatbelt Pillow?

Do you already have Drain Holders?

Please upload a screenshot showing your upcoming surgery or appointment

This is simply part of our verification process, to help ensure our donated resources reach women who are currently preparing for surgery or treatment. A screenshot of your patient portal, appointment confirmation, or hospital message is fine.

Where did you hear about us?

Do you have any comments, questions, or concerns?