Be Matched with One of Our Volunteers

If you have recently received a cancer diagnosis and would like to receive the support of a Friend for Life volunteer, please complete and submit the form below. We ask that you describe your situation in as much detail as possible, so that we can make a good match. If you are a family member or friend who would like to receive the support of one of our volunteers, please provide as much information about your loved one's diagnosis and note in one of the spaces provided your relationship to the person who has been diagnosed. 

Once you complete the form, click the "Submit" button, which will send your information to our Program Director. All personal information will be provided only to the Friend for Life Program Director and to the volunteer(s) with whom you are matched. 

Please provide the following information:

Your Name	
Street Address	
Address (cont.)	
City	
State	
Zip Code	
Work Phone	
Home Phone	
E-mail

Sex  Male Female

Date of birth   

Diagnosis   
(Please be as specific as possible -- eg. location, stage of cancer, etc.)

Date of Diagnosis                                            

Treatment: Please describe your treatment plan, if known. (Include surgeries, chemotherapy information, radiation, other therapies.

Details: Please add any information about your diagnosis or treatment that will better enable us to make a good match. If this is not the first time you have been diagnosed with cancer, please include this information as well.

Copyright © 2001 Friend for Life Cancer Support Network. All rights reserved.
Revised: August 05, 2001

 
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