Become a Living Beauty

GENERAL INFORMATION

First Name *

Last Name *

Email *

HOME Phone *

MOBILE Phone *

(used to send you text confirmations and updates)

Address *

Apartment, Suite, etc.

City *

State/Province *

Zip/Postal Code *

Country *

Birthday [MM/DD/YYYY] *

(Please click on the calendar icon and select a date.)

LIVING BEAUTY REGISTRATION

Approximate Annual Household Income *

How many people are in your household? *

Has your cancer impacted your household income? *

Has your cancer experience impacted your household expenses? *

(Optional) Please feel free to elaborate on the financial impact of your cancer experience.

Do you have children under the age of 18? If so, how many? *

(This question is for demographic purposes only. Please input "N/A" if you do not have any children under the age of 18.)

Marital Status *

Single

Married

Domestic Partnership

How would you self-identify your ethnicity? *

Asian/Pacific Islander

Black

Latina

Native American

White

Mixed Ethnicity

Other

I decline to answer.

(This question is solely for our own demographic program purposes.)

Date of your most recent diagnosis? [MM/DD/YYYY] *

(Please click on the calendar icon and select a date.)

(Optional) Year of your original diagnosis, if different from your most recent diagnosis?

Type of Cancer(s) *

What is your primary hospital? *

(Optional) Please list the programs/organizations that provide you support regarding your cancer diagnosis, as well as the type of support they provide.

(Optional) How did you hear about us?

(If a specific person referred you to the organization, please input their name.)

Where are you as you navigate your cancer diagnosis? *

(Optional) As of today, what are your greatest physical and emotional needs?

WAIVERS

Release of Liability (View at bit.ly/LBCF-RoL) *

Input your FULL LEGAL NAME. It acts as your signature and acknowledgment of liability.

Photo Release *

I grant Living Beauty Cancer Foundation the right and permission in respect of photographic portraits, pictures or videos that it has taken, to copyright the same, in its own name or otherwise; to use, re-use, publish, and re-publish the same in whole or in part, individually or in any and all media now or hereafter known, and for any purpose whatsoever, for illustration, promotion, art, editorial, advertising and trade, or any other purpose whatsoever without restriction as to alteration.

For privacy reasons, I prefer not to be photographed or my picture used in any social media posts. I take responsibility to alert the staff and/or event photographer of my request. I will be mindful to keep myself out of group pictures.

No Solicitation Policy (View at bit.ly/LBCF-NSP) *

I have read, understand, and agree to the no-solicitation policy.

Clicking the checkbox signifies that you have read, understand, and agree to the No Solicitation Policy.