Peer Support Leader Registration Form
Your contact details
Name *
Mailing address *
Email address *
Phone number
Your Breast Reconstruction Story
Your story helps us to match your experience with women seeking specific support.
Have you been diagnosed with breast cancer? *
Have you completed your breast cancer treatment NOT including BR surgery? *
If no, when do you expect to be complete?
What type of breast reconstruction procedures have you had? *
Required
What health system did you use through your surgeries? *
What hospital/s were your surgeries performed? *
Who were your surgeons? *
What month and year did you have your breast reconstruction surgery? *
Overall, how pleased are you with your breast reconstruction and add any comments regarding challenges you faced.
Your Support Options
What type of support would you like to offer? *
Required
Become a Reclaim Your Curves Ambassador. *
Tell us why you want to volunteer, what skills you bring to the role. *
Thank you
Do you have any further comments or questions about this role?
Submit
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