Adult & Family Program Information Form

Patient Information

This section should be filled out with information for the family member with a cancer diagnosis.

Coverage Area

You must be living in or treated in this eleven-county metro area of MINNESOTA (Anoka, Carver, Chisago, Dakota, Hennepin, Isanti, Ramsey, Scott, Sherburne, Washington, or Wright Counties).

How to Contact us

If you would like to speak to someone about our programming please call us at #612-627-9000.

Name*

First Last

Birthdate*

Sex*

Female
Male

Patient's Occupation*

Do you have health insurance?*

No
Yes

If so, please name your insurance provider*

This information is used to help us report on our programs and raise funds to continue to provide free programs and services. No individual information will ever be released and your response will not affect your ability to participate in our programs.

Patient's Place of Employment*

This information is used to help us report on our programs and raise funds to continue to provide free programs and services. No individual information will ever be released and your response will not affect your ability to participate in our programs.

Patient's Marital Status*

Veteran?*

No
Yes

Address*

Street Address Address Line 2 City State ZIP Code

County*

Patient's Primary Phone Number

Patient's Secondary Phone Number

Which phone number do you prefer to be contacted at?*

Home
Cell

Email Address

Would you like to receive information about our Emergency Financial Assistance program?

Yes
No

Annual Household Income Level*

This information is used for statistical reporting when Angel Foundation applies for grants to support our ability to provide free programs and services. No individual information is released.

Race/Ethnicity

This information is used for statistical reporting when Angel Foundation applies for grants to support our ability to provide free programs and services. No individual information is released.

Type of Cancer(s)*

Cancer Stage*

Date Diagnosed*

Has your child(ren) received an AngelPack backpack from your clinic/hospital?*

No
Yes

Are you currently in treatment?*

No
Yes

Type of treatment you have or will receive?*

Surgery
Chemotherapy
Radiation
Bone Marrow Transplant
Hospice
Palliative Care
Other

Where are you receiving treatment?

Have you experienced any recurrences?*

No
Yes

Family Information

In this section you will provide information for each of the family members that live in your household.

Spouse/Partner Information*

First Last

Spouse/Partner - Sex*

Female
Male
Other

Spouse/Partner - Birthdate*

Spouse/Partner - Email

Spouse/Partner - Sex*

Female
Male
Other

Spouse/Partner - Occupation

Spouse/Partner - Place of Employment

Spouse/Partner - Do you have health insurance?

Yes
No

Spouse/Partner - If so, please name your insurance provider

Child #1 - Name

First Last

Child #1 - Sex

Female
Male
Other

Child #1 - Birthdate

Child #1 - Relationship to Family Member with cancer:

Child #2 - Name

First Last

Child #2 - Sex

Female
Male
Other

Child #2 - Birthdate

Child #2 - Relationship to Family Member with cancer:

Additional Family Members

For additional family members not listed above, please include their first and last name, sex, birth date, and relationship to family member with cancer.

Do your child/ren have any special needs, disabilities, or medical conditions?

Please list the child's name, condition and any medications needed.

Does your family have any dietary restrictions?

Please list family member's name and restriction.

Is there anything else you would like to tell us about your family?

How did you hear about Angel Foundation?

How would you like to hear about upcoming Facing Cancer Together Programs?

Add my email to the Facing Cancer Together eBlast list

Please choose one or both options.

Liability Waiver*

I agree to the terms and conditions, explained below.

I hereby acknowledge and agree that I have voluntarily chosen to participate in Angel Foundation’s Facing Cancer Together program. I understand and agree that I must act in a careful, respectful, controlled, and appropriate manner, and follow any instructions given by Angel Foundation. If I have any questions about what is expected of me, I will make these known to Angel Foundation. I further understand and agree that Angel Foundation has the right to ask me to immediately discontinue participation in the activities if I am acting in a manner that is deemed inappropriate by Angel Foundation or for any other reason. I hereby agree that I, and anyone who has or obtains legal rights or claims through me, will not make a claim against, sue, or prosecute Angel Foundation or its Board of Directors or employees for any injury, death, property loss, or damage of any kind arising in connection with my participation at Angel Foundation and/or my travel to or from such activities. In addition, I hereby release and forever discharge Angel Foundation and its Board of Directors and employees from all actions, claims, or demands I, or anyone who has or obtains legal rights or claims through me, may have for any injury, death, property loss or damage of any kind arising in connection with my participation within Facing Cancer Together programs at Angel Foundation and/or my travel to and from such activities. I hereby assume all risks related to my participation as a volunteer with Angel Foundation and my travel to and from such activities. I have carefully read this agreement and fully understand its contents. I am aware that this is a release of liability and I sign it knowingly and voluntarily, and of my own free will.

Family Photo Release

I agree to the Family Photo Release, explained below.

Angel Foundation is a nonprofit charitable organization that provides non-medical services to cancer patients and their families. The purpose of this Release is to authorize Angel Foundation to use a photo and/or other information or data about you as described below, for purposes such as marketing and promoting Angel Foundation. 1. Your Information: "Your Information" includes all items and information you provide to Angel Foundation (for example, letters, photos, biographic information, and quotes) as well as things you let Angel Foundation record (for example, your voice, photograph, or video of you and your property), along with your name and biographic information such as the city in which you live. You agree that all rights, including copyright rights, in photographs or other images or recordings taken or made of you by Angel Foundation are owned by Angel Foundation. 2. Rights and Use by Angel Foundation: You agree that Angel Foundation, its successors, assigns, and any entity authorized by Angel Foundation, may use, re-use, edit, modify, publish, display, broadcast, distribute, revise, translate, reformat, create derivative works, copy, and make any commercial or other use of your information, in any electronic, physical, or other medium or format known now or later invented, for any purpose related to Angel Foundation, including but not limited to the marketing of and publicity for Angel Foundation, indefinitely and worldwide, without liability to you or any other person to use. 3. No Payment: You understand that you are not entitled to any royalty or compensation for the rights you grant in this Release. You grant these rights in consideration for the opportunity to have your Information used by Angel Foundation. 4. Release: You agree to release, defend, and hold harmless Angel Foundation, and its agents and employees, from and against any claims and damages for liability arising from or related to the use of your information in any form or format. 5. No Obligation to Use: You agree that Angel Foundation is under no obligation to use any information, nor is Angel Foundation under any obligation to submit materials that incorporate your information to you for your review or approval prior to any use, publication, or distribution of any kind. 6. True Information: To your knowledge, no information or statement that you provide under this Release is false, misleading, or defamatory. 7. Reading and Agreement: You have read this Release before signing, fully understanding the contents, meaning, and impact of this Release, and sign it voluntarily. 8. Age: You are at least 18 years old and have the full right, power, and authority to enter this Release on your own behalf. If you are under 18 years old, a parent or guardian must also sign below.

Please sign below (by typing your name) to confirm your response to the Family Photo Release*

Your Email*

Please provide your email so we may contact you if we have any questions about this form.

Comments

This field is for validation purposes and should be left unchanged.