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Caregiver Support Registration

Page Header Explanation (Internal: Hidden!)
Because some of the pages are conditional, there is a different header based on whether the person is:
* SS vs MA
* Previvor vs Cancer diagnosis

The result is the form is between 6 and 8 pages total.

The page headers are a conditional FA section with text inside.

Page 1 of 7: Terms and Conditions

Page 1 of 6: Terms and Conditions

Page 1 of 8: Terms and Conditions

Page 1 of 7: Terms and Conditions

Zero Tolerance Policy
Imerman Angels has the right to refuse matching services to people who exhibit and/or communicate racist, sexist, homophobic, xenophobic, and other discriminatory behavior. While we intend to serve all who need cancer support, those that don’t reflect our values of inclusivity and empathy will not be a good fit in our community.

Adherence to the Zero Tolerance Policy is mandatory to participate in Imerman Angel’s mentorship program.

Terms of Use
Imerman Angels (“IA”) is a nonprofit organization that provides one-on-one cancer support by connecting cancer fighters, survivors, caregivers, those who are high risk, and others seeking support (each a “Support Seeker”) with volunteer-mentors who have experienced something similar and donates their time and energy to IA and to those seeking support (each a “Mentor Angel”). IA’s one-on-one support gives each person seeking support a chance to ask personal questions and express their worries and frustrations, while receiving encouragement and support from someone who is uniquely familiar with the challenges that they may face.

By requesting support from a Mentor Angel or seeking to become a Mentor Angel (each Support Seeker and Mentor Angel referred to as a “Participant”) through IA and/or www.ImermanAngels.org (the “Website”), you expressly indicate that you understand and agree with the following:
  • The relationships established among any of the Participants are founded, and should be based, solely on psychosocial support and are not intended to be substitutes for professional treatment, advice or diagnosis. IA may refer Support Seekers to other agencies if IA personnel cannot find the appropriate match for the Support Seeker. 
  • Mentors Angels do not provide support as licensed medical or mental health/healthcare professionals. No Participant may recommend or endorse any specific medical or non-medical tests, physicians, products, procedures, opinions, or other information to another Participant or otherwise give “medical’ advice to another Participant. Further, no Participant should ever construe anything relayed to them by any other Participant as medical advice, recommendation or opinion. Under no circumstance should any Participant solicit or offer professional, financial, medical, or other similar advice or assistance from or to, respectively, another Participant. 
  • You will always seek the advice of your physician or other qualified health provider with any questions you may have regarding any medical condition, whether it be yours or another person’s. You will not disregard professional medical advice you have received from your doctors or delay in seeking professional medical advice because of a communication with another Participant or any IA officer, director, employee, or volunteer or because of something you have read on the Website. 
  • The content on the Website is only to be read and or used for informational purposes and is not intended to be a substitute for professional treatment, advice, or diagnosis. If at any time you have reason to believe you or a loved one may have a medical emergency or feel that you or a loved one need medical attention, please either call 911, go to the emergency room, and/or call your or their doctor, as appropriate, immediately. 
  • The information you provide to IA will only be used as described in IA’s Privacy Policy (www.ImermanAngels.org/privacy-policy) and you consent to all actions taken by IA with respect to your information in compliance with IA’s Privacy Policy. 
We at Imerman Angels are excited that you have found your way to our support community and look forward to the relationship that we will share with you.

PARENTS OR GUARDIANS OF MINORS (UNDER 18 YEARS OF AGE)

If the Participant is a minor (child under the age of 18 years) the undersigned parent and/or natural guardian or legal guardian of such participant does hereby represent that they are, in fact, acting in such capacity and agrees that they have read these terms and conditions and understand the policies of Imerman Angels laid out herein.

Page 2 of 7: Contact Information

Page 2 of 6: Contact Information

Page 2 of 8: Contact Information

Page 2 of 7: Contact Information

Hidden Fields
























By providing us your email address, you consent to being contacted by Imerman Angels for matching purposes including scheduling assessments, introduction to your Mentee or Mentor Angel and general correspondence from our Cancer Support Specialists.

Email Communication Preferences
In addition to being contacted by Imerman Angels for matching purposes, we also send communications regarding Imerman Angels news, events, resources, research opportunities and more! Please opt in to our mailing list if you would like to receive more from Imerman Angels. If you do not have an email address, you may skip this section.


If you cannot find your organization, select "Other"

If you cannot find your hospital, select "Other"

If you cannot find your workplace, select "Other"

Page 3 of 7: Demographic Information

Page 3 of 6: Demographic Information

Page 3 of 8: Demographic Information

Page 3 of 7: Demographic Information

By providing this information we can gain a greater sense of who you are in order to provide the best match. 

While we try to be as inclusive as possible, we recognize not everyone will fit into the categories below. If you find the options limiting, please select "Prefer to self identify."









MM/DD/YYYY format. This helps us match you with someone as close to your age as possible.






Please only select up to 5 employment industries


This is your preferred language for receiving/giving support to or from Imerman Angels. Please note that Imerman Angels staff can only provide services in English and Spanish.


This is an additional language you would feel comfortable using to receive/give support. Your fluency level should be strong enough to have a casual conversation using laymen medical terms.


This is an additional language you would feel comfortable using to receive/give support. Your fluency level should be strong enough to have a casual conversation using laymen medical terms.



Page 4 of 7: Information About Your Family Member or Friend

Page 4 of 6: Information About Your Family Member or Friend

Page 4 of 8: Information About Your Family Member or Friend

Page 4 of 7: Information About Your Family Member or Friend







MM/DD/YYYY format









If you selected "Other cancer treatment status" above please explain

If applicable, MM/DD/YYYY format. If you are not sure of the day/month, please enter approximate values.




MM/DD/YYYY format. If you are not certain of the day/month, please enter approximate values.





Page 5 of 7: Their Treatment Information

Page 5 of 8: Their Treatment Information



MM/DD/YYYY

If they have had/will have more than one type of treatment, please click the "Add another treatment" button below this section.

Treatment Details


Please tell us more about the treatment.


Page 6 of 8: Family and Lifestyle

Page 6 of 7: Family and Lifestyle







Calculated Children Age Groups (Hidden)
CONFIG NOTES: These fields are all calculated using the following calculation:
if(ChildAgeGroups!=""){if(ChildAgeGroups.includes("AGEGROUP")==true){"Yes"}else{"No"}}else{""};

The "AGEGROUP" is defined in the variable configuration for the "What ages were your children" question. Each age group below is specified in the calculation for that field.

For each of these fields below,  they will be either yes or no based on whether or not the checkbox has been selected. If the entire question is blank, ALL fields will be blank. Once one question has been selected, all unchecked will become "no" values.








(Example: running, biking, swimming, rowing, team sports, climbing, etc)


Page 6 of 7: Support Questions

Page 5 of 6: Support Questions

Page 7 of 8: Support Questions

Page 6 of 7: Support Questions


Select All That Apply

Select All That Apply



Select All That Apply


As a reminder, Imerman Angels has the right to refuse matching services to people who exhibit and/or communicate racist, sexist, homophobic, xenophobic, and other discriminatory behavior. While we intend to serve all who need cancer support, those that don’t reflect our values of inclusivity and empathy will not be a good fit in our community.

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Hidden Fields for Redirect


Contact Information