GBTP Ambassador Application

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We're so glad that you are interested in helping expand GBTP by becoming an ambassador! This application is a way for us to get to know a little bit more about you, your interests, and why'd like to represent GBTP as an ambassador.

First Name *

Last Name *

Date of Birth *

YYYY

Gender *

Please write in whatever term you feel comfortable with or N/a if you do not want to provide answer.

Race/Ethnicity *

Please check all that apply.

African / African American or Black

Asian / Pacific Islander

American Indian

Caucasion

Middle Eastern

Native American or Alaskan Native

Decline to state

Other:

Required

Relationship Status *

Single

Married

Divorced or Separated

Widowed

In a partnership

Do you have child(ren)? *

Yes

Date of diagnosis *

YYYY

Age of Diagnosis *

What type of breast cancer were you diagnosed with? *

Stage at diagnosis *

DCIS, Stage 0 (Non-Invasive)

Stage 1

Stage 2

Stage 3 (Large tumor, some node involvement)

Stage 4, Metastatic (Spread to other organs, like lungs, liver, brain, bones, etc)

Current Breast Cancer Related Status *

In treatment

1-2 yrs post active treatment

3-5 yrs post active treatment

6-10 yrs post active treatment

11+ yrs active treatment

Caregiver

Is your breast cancer metastatic? *

Yes, during treatment

Yes, after active treatment completed

Other:

What is / was your treatment plan? *

Please check all that apply.

Lumpectomy

Mastectomy

Reconstruction

Chemotherapy (infusion)

Chemotherapy (pill)

Hormonal treatment (ex: Tamoxifen, Anastrazole, etc)

Radiation treatment

Targeted therapy

Clinical trial

Fertility preservation

Other:

Required

What type of breast surgery did you have? *

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