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 diagnosisThe 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. I have read and agree to the Zero Tolerance Policy.YesNo Adherence to the Zero Tolerance Policy is mandatory to participate in Imerman Angel’s mentorship program. Require fieldChoice AChoice BChoice C 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. I have read and agree to the Terms of Use.Yes 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 SS Case Record Type Id MA Case Record Type Id Partner Code Partner Name Partner Account Id Partner Type Partner ReferralYesNo Case Priority Case Record Type Id SS Calendly Id MA Calendly Id SupportOrMentor Calendly Id for Redirect Would you like to:REQUEST a Mentor AngelBECOME a Mentor Angel First Name Last Name CountryPlease select... United States Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bolivia, Plurinational State of Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Darussalam Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo, the Democratic Republic of the Cook Islands Costa Rica Cote d'Ivoire Croatia Croatia ( Hrvatska ) Cuba Curaçao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See (Vatican City State) Honduras Hong Kong SAR Hungary Iceland India Indonesia Iran, Islamic Republic of Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea, Democratic People's Republic of Korea, Republic of Kuwait Kyrgyzstan Lao People's Democratic Republic Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia, the former Yugoslav Republic of Madagascar Malawi Malaysia Maldives Mali Malta Martinique Mauritania Mauritius Mayotte Mexico Moldova, Republic of Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Norway Oman Pakistan Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russian Federation Rwanda Saint Barthélemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka St. Pierre and Miquelon Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syrian Arab Republic Taiwan Tajikistan Tanzania, United Republic of Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Venezuela, Bolivarian Republic of Viet Nam Virgin Islands, British Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Street Address City State (US)Please select... Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Province (non-US)Please select... Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territories Zip or Postal Code Primary Phone Email Address 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. Has Email? (for redirect) 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. Yes, please send me information about Imerman Angels news, events, resources and more! Yes, I am interested in receiving information about participation in research studies. How did you hear about Imerman Angels?Please select... A Family Member Or Friend An Imerman Angels Representative Cancer Partner Organization Event, Race, or Team IA Marathon Healthcare Team (Doctor/Nurse/Social Worker) Media (TV, Radio, Magazine, Podcast, other) My Workplace Online Search Social Media (Facebook / Blog / Twitter) Other Book Insurance Lemonheads Church or religious/spiritual contact Prior user of Imerman Angels Point of Care Marketing Please start typing to specify the cancer partner organization If you cannot find your organization, select "Other" Please start typing to specify the hospital or healthcare team If you cannot find your hospital, select "Other" Please start typing to specify your workplace If you cannot find your workplace, select "Other" If other, please specify 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." Which category best describes your race/origin?American Indian or Alaska NativeAsianBlack or African AmericanHispanic/LatinxMiddle Eastern/North AfricanMulti-racialNative Hawaiian or Other Pacific IslanderWhitePrefer not to disclosePrefer to self identify Please share additional and more detailed information on how you self identify so that we can provide a more meaningful match (optional) Gender IdentityFemale MaleNonbinary TransgenderPrefer not to disclose Prefer to self identify In your own words, what is your gender identity? (optional) Sexual OrientationStraight (heterosexual) AsexualBisexual GayLesbianPansexualQueer QuestioningPrefer not to disclosePrefer to self identify In your own words, what is your sexual orientation? (optional) Personal Pronouns (optional; select all that apply)He/Him/HisShe/Her/HersThey/Them/TheirsZe/Hir/HirsNo pronounPrefer not to disclosePrefer to self identify In your own words, what are your personal pronouns? (optional) Date of Birth MM/DD/YYYY format. This helps us match you with someone as close to your age as possible. x Relationship StatusPlease select... Married Single Separated Significant Other Divorced Widowed/Widower Decline to Answer Employment StatusPlease select... Disability Full-Time Part-Time Retired Homemaker Unemployed Student Other Employer Employment Industry (select up to 5) Accounting Admin - Clerical Automotive Banking Biotech Business Development Business Opportunity Construction Consultant Customer Service Design Distribution - Shipping Education Engineering Executive Facilities Finance Franchise General Business General Labor Government Government - Federal Grocery Health Care Hospitality - Hotel Human Resources Information Technology Installation - Maint - Repair Insurance Inventory Legal Legal Admin Management Manufacturing Marketing Media - Journalism - Newspaper Nonprofit - Social Services Pharmaceutical Professional Services Purchasing - Procurement QA - Quality Control Real Estate Research Restaurant - Food Service Retail Sales Science Skilled Labor - Trades Strategy - Planning Supply Chain Telecommunications Training Transportation Veterinary Services Other If "Other", please let us know what your employment industry is Please only select up to 5 employment industries Industries Calculation Primary Language Please select... English Spanish American Sign Language Amharic Arabic Armenian Bengali Cantonese Croatian Dutch Finnish French French Creole German Greek Gujarati Hebrew Hindi Irish Gaelic Italian Japanese Korean Lithuanian Mandarin Persian Polish Portuguese Punjabi Romanian Russian Swedish Tagalog Thai Turkish Vietnamese OtherThis 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. Primary Language Secondary Language Please select... English Spanish American Sign Language Amharic Arabic Armenian Bengali Cantonese Croatian Dutch Finnish French French Creole German Greek Gujarati Hebrew Hindi Irish Gaelic Italian Japanese Korean Lithuanian Mandarin Persian Polish Portuguese Punjabi Romanian Russian Swedish Tagalog Thai Turkish Vietnamese OtherThis 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. Secondary Language Additional Language 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. Language (for redirect) Religion Agnostic Atheist Baha'i Baptist Buddhist Christian Christian-Catholic Hindu Jain Jehovah Witness Jewish Muslim Non-Religious/Secular Sikh Spiritual Unitarian Universalist Wiccan/Pagan/Druid Another Religion/Prefer to Self Identify In your own words, what is your religion? Page 4 of 7: Diagnosis Information Page 4 of 6: Diagnosis Information Page 4 of 8: Diagnosis Information Page 4 of 7: Diagnosis Information Diagnosis TypeCancerPrevivor/high-risk Previvor/High-Risk Treatment StatusPlease select... Undiagnosed/high-risk Wait and watch/under surveillance Newly diagnosed Seeking prophylactic options Started prophylactic treatment Completed prophylactic treatment Mutation TypePlease select... APC ATM AXIN2 BAP1 (tumor predisposition syndrome (TPDS)) BARD1 BHD (Birt-Hogg-Dubé syndrome) BMPR1A BRCA (Type Unknown) BRCA1 BRCA2 BRIP1 CDH1 CDK4 CDKN2A CHEK2 EPCAM FANCC FH HLRCC (Hereditary leiomyomatosis and renal cell cancer) HPRC (Hereditary papillary renal cancer) Lynch Syndrome (Type Unknown) MAX MEN 1 MEN 2 MLH1 MSH2 MSH6 MUTYH NBN NF1 Other PALB2 PMS2 PTEN RAD50 RAD51C RAD51D RET SDHA SDHAF2 SDHB SDHC SDHD SMAD4 STK11 TMEM127 TP53 TSC (Tuberous sclerosis complex) TSC1 TSC2 VHL (Von Hippel-Lindau) XRCC2 Other Mutation Type Cancer Treatment StatusPlease select... Newly diagnosed Currently in treatment Finished treatment less than 1 year ago Finished between 1 and 5 years ago Finished more than 5 years ago Living with cancer as a chronic illness Receiving hospice or palliative care Other Other Cancer Treatment Status If you selected "Other cancer treatment status" above please explain Cancer Type Cancer Sub-Type Cancer Stage or GradePlease select... 0 1 2 3 4 Unknown Not applicable Date Diagnosed (Approximately) MM/DD/YYYY format. If you are not certain of the day or month, please enter approximate values. x Did this cancer metastasize? (Did the cancer spread?)Please select... Yes No I'm not sure Metastasis Location Did this cancer recur?YesNo Recurrence Diagnosis Date (approximate) Recurrence Location Page 5 of 7: Treatment Information Page 5 of 8: Treatment Information Do you need to be connected with a Mentor Angel because you have an imminent treatment or procedure scheduled? (Please note that reoccurring and/or regularly scheduled doctor visits, scans, radiation treatments and/or therapies do not qualify as imminent procedures)YesNo When is the treatment or procedure? MM/DD/YYYY Please supply additional information about your procedure and needs below If you have had/will have more than one type of treatment, please click the "Add another treatment" button below this section. Treatment Details What treatment are/were/will you be given? Bone Marrow Transplant Chemotherapy Radiation Stem Cell Transplant Surgery Wait and Watch Alternative Treatment Other Description Please tell us more about the treatment. Is this treatment part of a clinical trial?YesNo/Not Applicable Please indicate which side effects you've experienced Allergic Reactions Anxiety Bone Pain Bowel Management Burns Depression Fertility Changes Graft vs Host Disease Hair Loss Infection Lymphedema Neuropathy Phantom Pain Sexual Dysfunction Urinary Issues Other Side Effect(s) Other Side Effects Page 6 of 8: Family and Lifestyle Page 6 of 7: Family and Lifestyle Did you seek any fertility/family building services as a result of your diagnosis?YesNo Please specify: Adoption Cord blood banking Egg freezing Embryo freezing Ovarian tissue freezing Preimplantation genetic profiling Sperm banking Surrogacy Other If other, please specify Do you have children?Please select... Yes No How many children do you have? What ages were your children during your initial diagnosis experience? (Select all that apply)Prenatal0-12 MonthsToddlerPreschoolerGradeschoolerTeenAdult 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. Prenatal Baby Toddler Preschooler Gradeschooler Teen Adult Did you participate in any high-intensity sports during or after your diagnosis? YesNo(Example: running, biking, swimming, rowing, team sports, climbing, etc) Did you make any dietary changes as a result of your diagnosis?YesNo If you answered yes, please specify:VeganVegetarianLow-AlkalineOther Edit this text Page 6 of 7: Support Questions Page 5 of 6: Support Questions Page 7 of 8: Support Questions Page 6 of 7: Support Questions Why are you interested in becoming a Mentor Angel? Want to give back and help othersWish I had help from someone who understood what I was going through during my diagnosis experienceWant friendship and/or companionshipIn honor or in memory of someoneFor religious or spiritual reasonsHelp me through my healing processSelect All That Apply How would you prefer to communicate with the person you're matched with? EmailPhoneTextVideo chatWhatsAppSelect All That Apply How often do you think you would like to communicate with your personalized match?One or two conversationsWeeklyI'm not sureAs much as is needed In your own words, please tell us anything else that you feel contributes to your ability to be a Mentor Angel. Which of the following would you like to speak with a peer (a Mentor Angel) about? I just want to speak with someone who understands what I'm going throughTheir experience with a particular treatment or participation in a clinical trialParenting and diagnosisCommunicating with family/friendsFertility/family buildingSex/dating/relationshipsChanges to dietParticipating in high-intensity sports after diagnosisAdjusting to life after diagnosisHow to deal with anxietyHow to start conversations about end of life careOtherSelect All That Apply If other, please specify Please tell us anything else about your story to help us find you the best possible Mentor Angel: 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. Important! The next page may take a moment to load.Only press "Next Page" ONE time. Do not close this window. Hidden Fields for Redirect SS or MA Diagnosis: Previvor or Cancer Contact Information