Application Test Page - Little Pink Houses of Hope

"*" indicates required fields

Step 1 of 9

Breast Cancer Applicant Information

Fields with asterisks (*) are required and must be filled in.

Name*

First Last

Street Address*

Address Line 2

City*

State / Province / Region*

Zip / Postal Code*

Country*

Email*

Mobile/Main Phone*

Date of Birth*

Gender*

T-Shirt Size*

Statistical Information

To assist us with future program development and funding, please complete the following fields. Your answers below will NOT be used in our selection process.

*If using your phone reduce your font size and turn your phone sideways to see all choices*

Are you concerned about the additional stress of your cancer diagnosis on your family?*

Yes	No	I do not wish to answer

_______________________________________________________

Ethnicity*

Asian or Pacific Islander

Black or African-American

Hispanic or Latino

Multi-Racial or Biracial

Native American or Alaskan Native

White or Caucasian

A race/ ethnicity not listed here

I wish not to provide

_______________________________________________________

Occupation

Employer

Total Household Income*

$0 to $50,000 per year

$50,001 to $100,000 per year

$100,001 to $150,000 per year

$150,000 per year or more

I do not wish to provide this information

Little Pink has instituted a travel assistance program to help with travel expenses to the retreat location (based on securing funding). You can check https://www.littlepink.org/travel/ to view income verification guidelines. Based on this information, would you plan on submitting an application for travel assistance if accepted for a retreat? **This does not guarantee travel and does not substitute for an official application*** This information will NOT be used as part of your acceptance consideration. It is strictly to help guide us as we work to secure additional funding. DO NOT FILL OUT TRAVEL ASSISTANCE APPLICATION UNTIL YOU HAVE BEEN ACCEPTED!

Travel Assistance*

Please choose whether or not you would apply to Travel Assistance, if offered:

Yes

_______________________________________________________

How did you hear about Little Pink?*

Social Media

Blog

Doctor/Hospital

Conference

Website/Internet Search

Friend

Someone that attended a retreat previously

I do not wish to answer

Other

How did you hear 'other'?*

_______________________________________________________

Breast Cancer Confirmation*

I confirm that I have been diagnosed with breast cancer and all answers I will give in this application regarding treatment and diagnosis will be related to my breast cancer diagnosis only.

Yes

We are sorry, you are not eligible to apply for a retreat.
Little Pink Houses of Hope serves only breast cancer patients at this time. We know anyone facing cancer deserves this type of vacation, but at the time we are only able to serve the breast cancer community.

Medical Doctor and Facility Information

Breast Cancer Oncologist Name*

First Last

Medical Facility Name*

Oncologist Street Address*

Address Line 2

City*

State / Province / Region*

Zip / Postal Code*

Country*

Oncologist Phone*

_______________________________________________________

Family Member Information

Please only include immediate Family or Caregiver(s). Our retreats are possible because of donated properties. Retreats are designed to encourage your core family living in your home or key caregivers/friends that help you daily.

Number of family members - NOT INCLUDING YOU.*

Please enter the number of eligible person(s) you would like to attend the retreat with you.

Please enter a number from 0 to 8.

_______________________________________________________

Please name your spouse, partner or caregiver in the first slot if they will be attending the retreat with you. If no other Adult is coming with you, select Additional Person 1.

Person Attending*

Spouse/Partner or Main Caregiver

Additional Person 1

Name*

First Last

Cell Phone

Date of Birth

Current Age

Gender

T-Shirt Size

Relationship to YOU.

Other Relationship to YOU.

_________END ADDITIONAL PERSON 1_________

Additional Person 2 Name*

First Last

Additional Person 2 Date of Birth*

Additional Person 2 Current Age*

If less than 1, enter 0.

Additional Person 2 Gender*

Additional Person 2 Relationship to YOU.*

Additional Person 2 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 2_________

Additional Person 3 Name*

First Last

Additional Person 3 Date of Birth*

Additional Person 3 Current Age*

If less than 1, enter 0.

Additional Person 3 Gender*

Additional Person 3 Relationship to YOU.*

Additional Person 3 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 3_________

Additional Person 4 Name*

First Last

Additional Person 4 Date of Birth*

Additional Person 4 Current Age*

If less than 1, enter 0.

Additional Person 4 Gender*

Additional Person 4 Relationship to YOU.*

Additional Person 4 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 4_________

Additional Person 5 Name*

First Last

Additional Person 5 Date of Birth*

Additional Person 5 Current Age*

If less than 1, enter 0.

Additional Person 5 Gender*

Additional Person 5 Relationship to YOU.*

Additional Person 5 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 5_________

Additional Person 6 Name*

First Last

Additional Person 6 Date of Birth*

Additional Person 6 Current Age*

If less than 1, enter 0.

Additional Person 6 Gender*

Additional Person 6 Relationship to YOU.*

Additional Person 6 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 6_________

Additional Person 7 Name*

First Last

Additional Person 7 Date of Birth*

Additional Person 7 Current Age*

If less than 1, enter 0.

Additional Person 7 Gender*

Additional Person 7 Relationship to YOU.*

Additional Person 7 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 7_________

Additional Person 8 Name*

First Last

Additional Person 8 Date of Birth*

Additional Person 8 Current Age*

If less than 1, enter 0.

Additional Person 8 Gender*

Additional Person 8 Relationship to YOU.*

Additional Person 8 Other Relationship to YOU.*

_________END ADDITIONAL PERSON 8_________