Quick Registration | Imerman Angels

START HERE! Please tell us more about yourself. Select from the options below.

I am registering to RECEIVE a mentor
I am registering to BECOME a mentor

I am a...

Cancer Fighter/Patient
Caregiver to a Fighter/Patient
Previvor/High Risk
Social Worker/Practitioner

I am a...

Cancer Survivor
Caregiver to a Survivor
Previvor/High Risk
Social Worker/Practitioner

Name of Referral Location or Event

If applicable, please tell us the name of the event, conference or location where you scanned our QR code.

Contact Information

Attention Social Workers/Practitioners:

Unless otherwise stated, please supply your patient's information in the fields below.

By submitting this form to Imerman Angels at the direction of the Fighter/Survivor listed below, Hospital/Partner/Practitioner certifies that it has obtained from Fighter/Survivor required and applicable consents and authorizations to share Fighter’s/Survivor’s personal information, including but not limited to, authorizations required under the Health Insurance Portability and Accountability Act Privacy Rule and any applicable state privacy laws.

Name

First

Last

Patient's Name

First

Last

Caregivee's Name

First

Last

Caregivers please supply the name of your Caregivee.

Relationship

Caregivers please tell us your relationship to your Caregivee named above (i.e. my spouse/partner, my parent, my child, etc.).

Social Worker/Practitioner's Name

First

Last

Treatment Location

Social Workers/Practitioners please supply the name of your hospital, clinic or cancer center.

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country (if located outside of the United States)

selection the Please

Phone

Email

Date of Birth

Gender Identity

Diagnosis & Treatment Information

Type of Cancer

Please supply the name of your/your Caregivee's cancer diagnosis.

Genetic Mutation or Cancer Risk

Please supply the name of your genetic mutation or the name of the cancer type you're at risk for.

Date of Diagnosis

Note: if you don't know/remember the exact date of your diagnosis please use the first day of the month of you were diagnosed (i.e. "12/01/2020" for "December 2020")

Stage of Cancer

Treatment Status

If "Other" please specify below:

Please confirm your cancer treatment status. If you selected "receiving hospice care" by mistake, please update your selection above.

Yes, I am currently receiving hospice care

Hospice Care Resources

Thank you for considering Imerman Angels to support you through your cancer journey. Based on the answers you provided during the registration process and your hospice status, we would not be an appropriate resource for your needs. Our Mentor Angels offer support by sharing their lived experiences, but they are not trained to navigate or provide guidance around hospice care. Click here to download resources you may find helpful during hospice care.

That said, we can provide support for your family members, friends, or loved ones acting as caregivers for you. If they are interested in connecting with a Caregiver Mentor Angel who has walked a similar path, please direct them to register with us at https://imermanangels.org/find-mentor-angel/.

Thank you again for contacting us, and we wish you all the best.