Lifted by Angels Nominations for Chemo Care Packages-2019
At Lifted by Angels we work for and lift young moms battling cancer. I am so excited to hear about your loved ones.
We understand you are possibly a friend, family member or co-worker and may not know some of this information. Please answer to the best of your abilities.
In order to nominate, the nominee must be a Utah Resident and live between Weber County and Utah County.
Nominee's full name? *
Your answer
Relationship to nominee? *
Your answer
Best contact email for you? *
Your answer
Was nominee diagnosed within the last 6 months? *
First time having cancer? *
Type of cancer? *
Your answer
City of residency? (Must be in Utah between Weber and Utah County) *
Your answer
Age of nominee? *
Your answer
Marital Status? *
Your answer
Number of children? *
Your answer
Children’s ages? *
Your answer
Household Income? *
Your answer
Vocation of nominee? *
Your answer
Spouses vocation if applicable *
Your answer
Does nominee have health insurance? *
Type of treatment receiving, received or will receive soon? *
Your answer
What would benefit this family most? Financial support, community support, help with meals, childcare etc… *
Your answer
Is she interested in holistic therapy? *
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This form was created inside of XOXO Hats for Strength.