Cancer Alliance for Research, Education and Survivorship

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As a cancer survivor, you’ve been there. Now there is something you can do to help. You can become a 4th Angel volunteer mentor and support others who have been diagnosed with cancer. After receiving professionally facilitated training, you will be ready to share, one-on-one, your positive outlook, warmth and concern, as well as the practical knowledge you gained from your cancer experience. Any cancer survivor is eligible to join the 4th Angel Mentoring Program.

To volunteer with the 4th Angel Program, complete the application below or call 866-520-3197 for more information.

Register As Mentor
First Name:
Last Name:
Address:
City:
State:
Zip:
Home Phone: () - 
Work Phone: () - 
Cell Phone: () - 
Best Time to call:
Email:
Preferred Method of Contact?
Date Of Birth: (mm/dd/yyyy)
Gender:
Type of Cancer:
Stage of Cancer:
Diagnosis Date: (mm/yyyy)
Date Of Last Treatment: (mm/yyyy)
What type of treatment did you have? Please check all that apply:


 





 


















Please indicate which of the following was most stressful for you at the time of diagnosis. Then indicate if these issues are still a concern to you.
    Career / Job
    Emotional Distress
    Fatigue
    Fear Of Death
    Fear of Recurrance
    Fertility
    Finances
    Nutritional Concerns
    Parenting
    Physical Changes
    Relationships
    Sexuality
   
Where were you treated (Hospital)?
Treatment Notes?
Are there any particular issues that you feel stand out more that others?
Marital Status:
Do you have children?
Employment Status during treatment:
Current Employment Status:
Foreign Languages spoken:
Notes / Interests:
Why do you want to be a mentor?
How did you hear about 4th Angel?
Do you have previous volunteer experience?

Volunteer Program
Dates of Service
Volunteer Program
Dates of Service
Have you ever been convicted of a felony or misdemeanor?

A conviction does not necessarily disqualify an applicant. Failure to disclose may result in disqualification or termination.
If yes, please describe the offense:

I hereby confirm that the information provided in the above web application form is true and complete to the best of my knowledge. I understand that providing false information may disqualify me from consideration as a volunteer. My act of filling out the aforementioned form gives my consent to perform a backfround check. I will consider all information that I gain in my volunteer position to be confidentail. I understand that my volunteer service will be terminated in an event of breach of confidentiality.