The Ruth and Sidney Vine Peer Support Network Registration Please only fill out this form once. Name* First Last Email* Best phone number*Your Location* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Date of Birth* MM slash DD slash YYYY Date of Diagnosis MM slash DD slash YYYY Age at DiagnosisI am* Newly diagnosed with breast cancer Newly diagnosed with ovarian cancer Currently in treatment for breast cancer Currently in treatment for ovarian cancer Done with active treatment for breast cancer Done with active treatment for ovarian cancer At high risk for developing breast or ovarian cancer At high risk due to a genetic mutation (BRCA, CHEK2, etc.) Friend/family of someone with breast/ovarian cancer Healthcare Provider Other I am interested in the following FREE services offered by phone, mail & e-mail (check all that apply):* Peer Support Network: Peer connections based on similar concerns & diagnoses Tailored support and resources for women with advanced or metastatic cancer Busy Box®: Support for parents of children with age-appropriate toys Young ADult Caring Corner: Peer support for those aged 18-25 with a loved one facing cancer Makeup and skincare kit that addresses the cosmetic side effects of treatment with makeup instructions & beauty products Best Face Forward® 2.0: Need-based financial subsidies for wigs, scalp cooling & 3-D micropigmentation Thriving Again® Kit: Healthy living tools for survivorship Financial Wellness Toolkit: Helpful resources, tips & information Support for family members, caregivers & friends PGT Kit: Information about using IVF and screening of embryos to build a family Genetics for Life®: Speak with a genetic counselor about hereditary cancer risk Treatment Care Kit: Practical resources and supportive essentials to help navigate treatment and manage side effects. Peer Support I would like to receive Peer Support I would like to give Peer Support I would like to discuss my concerns regarding (Check all the apply.) Genetics Surgery Treatment (chemotherapy, radiation, hormonal therapy, etc.) Parenting Fertility Finances Nutrition and Exercise Survivorship Health Care Professionals Other Busy Box - Ages and gender of your child(ren):Young Adult Caring Corner I would like to receive Buddy Support I would like to give Buddy Support My loved one is (check all that apply):* Newly dx with breast cancer Newly dx with ovarian cancer Currently in treatment for breast cancer Currently in treatment for ovarian cancer Done with active treatment for breast cancer Done with active treatment for ovarian cancer At high risk for developing breast or ovarian cancer At high risk due to a genetic mutation (BRCA, CHEK2, etc.) Other I would like to discuss my concerns regarding (check all that apply):* Genetics Treatment (chemotherapy, radiation, surgery, etc.) Caregiving at Home Long-Distance Caregiving Self-Care Other Services Requesting* Scalp Cooling* Cranial Prothesis (Wig) *You can only apply to one funding source for scalp cooling, if you already applied to Hair To Stay, you will unfortunately not be able to apply for this program.Please select your customized Survivorship Kit*Breast CancerMetastatic breast cancerOvarian cancerAdvanced ovarian cancerCookbookN/ABack in the SwingCancer Diet For the Newly Diagnosed (Kosher Cookbook)One bite at a timeAdditional Comments Made possible with support from:
