12-Month Cancer & Caregiver Mentorship Program Application
Thank you for your interest in joining our 12-month mentorship journey. This program is designed to support women diagnosed with cancer and the caregivers who walk beside them. Please complete the form below so we can learn how to best support you.
Email *
Name *
First and last name
Email *
Phone number *
Are you applying as: *
Required
  Diagnosis or Caregiving Information  - copy and paste this into the answer section

If diagnosed:
Type of cancer:
Stage (if known):
Date of diagnosis:
Are you currently in treatment? ☐ Yes ☐ No
If yes, what type of treatment?

If caregiver:
Relationship to the woman diagnosed:
How long have you been in the caregiving role?

 *
  What are the biggest challenges you are currently facing?
(Physical, emotional, financial, spiritual, etc.)   *
  What type of support are you hoping to receive in this program?   *
  What would feeling supported over the next 12 months look like for you?   *
 This is a 12-month mentorship program that includes community support, mentorship matching, wellness experiences, and check-ins.   Are you able to commit to participating for 12 months? *
 Is there anything else you would like us to know about you?   *
 How did you hear about The Shenomenal Foundation?   *
Consent

I understand that this program is for support and mentorship and does not replace medical or professional care.

 *
 By typing my name and date below, I confirm that the information provided is true and accurate to the best of my knowledge, and I consent to being contacted by a representative of The Shenomenal Foundation regarding this application.   *
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