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 *

Zip *

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

Asian/Pacific Islander

Black

Latina

Native American

White

Mixed Ethnicity

Other

I decline to answer.

Date of your most recent diagnosis? [MM/DD/YYYY] (Please click on the calendar icon and choose 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: I voluntarily participate with full knowledge that there is risk of personal injury (including death), property damage and/or other loss. On behalf of myself, my heirs, personal representatives, and executors, I hereby release, discharge, indemnify, and hold harmless Living Beauty Cancer Foundation, its subsidiaries and affiliates, and their respective officers, directors, employees, volunteers, and agents from and against any and all losses, liabilities, damages, actions, suites, demand or claims, of any nature or cause (each, a Claim), including costs and attorney's fees incurred by Living Beauty Cancer Foundation in connection with such Claim, arising from damages or injuries which may be sustained or caused by me, directly or indirectly, in connection with my participation with Living Beauty Cancer Foundation, whether or not caused by Living Beauty Cancer Foundation or it's officers, directors, employees, or agents or otherwise. By typing my name in this form, I agree that Living Beauty Cancer Foundation is in no way responsible for the safekeeping of any personal belongings while I attend Living Beauty events. My FULL LEGAL NAME here acts as my 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: Here at Living Beauty Cancer Foundation, we are mindful of the financial hardships that cancer may cause. All of our programs are free of charge, and we only promote programs or resources outside of the organization that are free as well. As a registered Living Beauty, you must agree to our no-solicitation policy. This policy states that you will not solicit other Living Beauties to promote your own business or programs at our events unless permitted by Living Beauty Staff.

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

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