Treatment Kit Request for a Loved One
Here at Michigan Faith in the Fight (MFITF), we are here to make sure that after a diagnosis of cancer, your loved one is supported through treatment and beyond. In order to do this safely and effectively, we need to start by asking a few questions so we can be sure to send your friend/family FREE treatment kit. Please fill out the questions the best you can about the person you wish to receive the support kit. Please let the recipient of the kit knows that you have arranged for something to be sent to them and that we may contact them through email to confirm information to ensure their safety is of upmost importance. By completing this form for a friend/family member you are taking responsibility that the information below is accurate and are agreeing that you are ordering this kit as a gift from you to them. You agree that any/all of the contents be reviewed by their primary oncology team prior to using the contents of the donated supportive kit.

This organization is fully volunteer operated and if at any time you are able to donate towards our services, we would greatly appreciate it.

We are honored to have the opportunity to provide support that may help make this journey through treatment easier. Faith in the Fight, Inc. may provide support in various forms. These may include informational sources, donated items (i.e. including, but not limited to; over the counter medications, topical lotions and other products), suggestions from other individuals who have undergone treatments, and/or financial support.
In consideration for the opportunity to utilize any and/or all of the above services/donated items, you acknowledge and accept that it is your responsibility to discuss any and all services or donated items with your medical provider prior to use. You agree to accept any and all risks associated with any item, advice or service received through Faith in the Fight, Inc. The requestee of the supportive kit on this form accepts full responsibility and agree to hold harmless, indemnify and defend Faith in the Fight, Inc. its Board, officers, employees, volunteers, and agents, from any liability, damages, loss, claims, demands, actions, expenses and costs arising out of, directly or indirectly, your utilizing any of the services or donated items provided. This includes any injury that arises out of the recipients use, your use of any donated items, or the recipients or your own negligence.

By signing below, you acknowledge that you have read the above statement and consent to the terms.

Now, LET'S GET STARTED!
**All info is HIPAA Compliant**

Sign in to Google to save your progress. Learn more
Email *
How did you
Clear selection
Name (Requestor's/Your Name) *
Phone Number (Requestor's/Your Phone Number with Area Code) *
Who is this Supportive Kit For? Please Provide their First and Last Name. *
Address (city, and zip are required) - Where are we shipping (To you or your loved one - Must Label Who's Address is Listed)) *
1 point
Phone Number of the Supportive Kit Recipient *
1 point
Email of the Supportive Kit Recipient *
Preferred Method of Contact (In the Event we need to clarify information with the recipient of this kit what is the best way to contact them?) *
Required
Does the Recipient of this kit have any ALLERGIES? If so, PLease List, If unsure, type "Unsure" and we will contact them prior to shipping their support kit. *
1 point
Date of Birth XX/XX/XXXX (The Recipient) *
1 point
MM
/
DD
/
YYYY
Gender (The Recipient) *
Type of Cancer *
Stage of Cancer *
Date of Diagnosis (Estimated Date) *
MM
/
DD
/
YYYY
Treatment Plan (Please check all that apply)
Check all that apply: If you know they are struggling with any of the following. *
Required
I have read all of the terms of consent and acknowledge that you have read the above statement and consent to the terms. *
By signing this section, the party agree and accept the terms that this is a valid electronic signature. The party agrees that the electronic signatures appearing on this document are the same as handwritten signatures for the purpose of validity, enforceability, and admissibility. *
Agree to the use of electronic signature. *
Your Message to the Recipient. (We will include a card from you inside their support kit, write a message on what you would like it to say). *
Disclaimer: Safety and Privacy are taken very serious at MFITF therefore if we need further information and cannot obtain, the requester of the kit will be contacted, certain information must be obtained prior to shipment, if unable to obtain this will delay and possibly cancel shipment of your requested support kit. *
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Faith in the Fight, inc. DBA: Michigan Faith in the Fight. Report Abuse