Angel Mentor Application

Contact Information

Name

First Last

Date

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone (Home)

Phone (Cell)

Phone (Work)

(Only if we may call you at work)

What is the best way to contact you?

Demographic Information

Birth date

Gender

Race / Ethnicity

Relationship Status

Single
Married
Partnered
Divorced
Widowed
Separated

Do you have children?

Yes
No

Number of Children

Children's age(s) at time of your diagnosis

Employment

Full Time
Part Time
Not employed
Retired

Cancer Experience

Providing as much detail as possible about your cancer experience helps ESCA make better matches with callers.

What was the date of your (initial) diagnosis?

How old were you when you were diagnosed?

What was your specific cancer diagnosis? (Please be as detailed as possible.)

Have you had a cancer recurrence? If you have, please describe and provide date(s).

Have you been diagnosed with other cancers? If so, please provide details, including diagnosis date(s).

Treatments

Surgery

Please list any cancer-related surgeries you have had and include dates.

Chemotherapy

Please describe any chemotherapy you have had, providing as much detail as possible, including medications used, frequency of treatments and side effects.

Radiation

If you were treated with radiation, please provide as much detail as possible, including frequency and length of treatment and any side effects.

Hobbies & Skills

Please list any hobbies, skills or special interests you have.

Character Reference

I authorize an ESCA representative to contact these persons to obtain a personal character reference:

Name

First Last

Phone

Email

Name

First Last

Phone

Email

Name

First Last

Phone

Email

Date

Signature