Team Michelle Care package request form

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Team Michelle Care Packages are for anyone going through breast cancer diagnosis, treatment or post treatment that could use a little pick me up! Please complete form and a care package will be sent (or ready for pick up) to be delivered to your survivor. For more information or to support our care package program go to teammichelle.com

Email *

Your name *

Your Phone Number *

How did you hear about Team Michelle *

I am a Volunteer/Team Member

I am a past recipient of a care package or Acts of Love

I am a supporter of Team Michelle

I found information through a web/google search

Other:

Required

Name of recipient of care package *

Mail or Hand delivered (pick up care basket in Silverado, CA)

Please mail package

I will pick up from Buessing home in Silverado and deliver myself

Clear selection

Address of Recipient *

Additional comments/info

A copy of your responses will be emailed to the address you provided.

Submit

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