AngelPack Request Form AngelPack Request Step 1 of 4 - Angel Packs 25% All information provided will remain confidential.Date* MM slash DD slash YYYY Patient's Name* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please document the number of packs needed for each age group and the relationship to the patient.Teen*Relationship to patient Preteen*Relationship to patient Child*Relationship to patient Would like to be contacted about Angel Foundation™ programs?* Yes No If yes, please indicate the preferred method for contact Mail Email Phone Patient Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code County Patient Email Enter Email Confirm Email Daytime PhoneMay we leave a message? Yes No Primary Language* English Gender*Your responses to the following question enable Angel Foundation™ to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes. Female Male Non-Conforming/Non-Binary Prefer not to answer Two Spirit Racial/Ethnic Identity(s)*Your responses to the following question enable Angel Foundation™ to better serve communities equitably. All responses are kept private and secured and will NOT be used for discriminatory purposes. American Indian or Alaska Native Asian, Native Hawaiian, or Pacific islander Black or African American Hispanic, Latina/o/x, Spanish Origin Middle Eastern or North African Non-Hispanic White Prefer not to answer Two or More Races Type and Stage of Cancer* Clinic Name and Location* Additional CommentsFor example: We are waiting to tell our children about the cancer diagnosis until after receiving the Angel Packs™ , so we would need them as soon as possible.Who is completing this request?* Patient Healthcare Provider Family/Friend on behalf of patient Requester Name and Role* Requester E-mail* Requester PhoneI hereby declare the information on this application is true and correct to the best of my knowledge. I understand that all information reviewed will be kept confidential. In addition, I am aware that Angel Foundation™ will contact me about this form and/or if I indicated I would like to be contacted about programs. By checking the box below and submitting this application I am acknowledging that I am giving permission for Angel Foundation™ to verify my cancer diagnosis with a healthcare provider at my clinic.* I understand and provide permission I hereby declare the information provided on this application is true and correct to the best of my knowledge. I understand that all information reviewed will be kept confidential. In addition, the patient is aware that Angel Foundation™ will contact them if there are questions about this form and/or if I indicated they would like to be contacted about programs. By checking the box below and submitting this application you are acknowledging that the patient has given permission for Angel Foundation™ to verify the patient's cancer diagnosis with a healthcare provider at their clinic.* I understand and provide permission I understand that the information provided on this form will be kept confidential and the patient will only be contacted by Angel Foundation™ if they have indicated they would like to be contacted about programs.* I understand and provide permission Please sign below (by typing your name) to authorize the patient release.* Δ