Imerman Angels Cancer Support Form

Contact Information






Address








Providing an email enables us to more effectively respond to your needs and support requests. We are committed to your privacy and your email will never be shared with an outside party.






Demographic Information

These questions help us find you the most similar match possible. 


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














Cancer Information



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





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





Treatment Information



Please tell us more about the treatment.

Add another treatment

If you have had more than one type of treatment, please click Add another treatment.

Family and Lifestyle





If yes, how many children are living with you at each of the following ages?  Click the Add link to add another row if needed.



Add another entry for children

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


Support Questions


Select All That Apply

Select All That Apply



Select All That Apply


Survey

NOTE: All questions are required.

Looking back on the past week, including today, how often have you felt each of the following? 

1 - never 2 - once in a while 3 - sometimes 4 - often 5 - always

Please rate to the extent that you agree with the following statements:

1 - strongly disagree 2 - disagree 3 - neither disagree nor agree 4 - agree 5 - strongly agree

Terms of Use

Imerman Angels ("IA") is a not-for-profit organization that provides "1-on-1 Cancer Support" assistance by connecting people who are currently fighting cancer (each, a "Fighter") with another individual who has beaten cancer, ideally the same kind of cancer, in his or her lifetime (each, a "Survivor"). Oftentimes, a family member or friend of a Fighter will seek support from IA (a "Caregiver" and, together with Fighters and Survivors, "Participants") and IA gladly pairs them with Survivors as well. IA's "1-on-1 Cancer Support" gives each Fighter and/or Caregiver a chance to ask personal questions and express his or her worries and frustrations to, while receiving encouragement and support from, someone who is uniquely familiar with the challenges that Fighters and/or Caregivers face.

Survivors are volunteer-mentors only and donate their time and energy to IA and to the Fighters with whom they develop contacts and relationships. Participants (Survivors or otherwise) are not, and are not part of the IA network to act as, licensed medical or mental health/healthcare professionals. IA’s policy and express instruction to each Participant is that 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 him or her by any other Participant as medical advice, recommendation, or opinion. The sole purpose of the relationships set up through IA is the offering and receipt of cancer support. Under no circumstance should any Participant solicit or offer professional, financial, medical, or other similar advice or assistance from or to, respectively, another Participant.

By answering the question below, you (a Participant) expressly indicate your understanding that the relationships established among any of the Participants are founded, and should be based, solely on support (as indicated herein) and are not intended to be substitutes for professional treatment, advice, or diagnosis. 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. Please do not disregard professional medical advice you have received from your doctors or delay in seeking professional medical advice because of a communication with another IA member (Fighter, Survivor, Caregiver, or any IA officer, director, employee, or other volunteer) or because of something you have read on our website. The content of IA’s website (www.imermanangels.org) 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.

We at Imerman Angels are excited that you have found your way to our support network 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 he/she is, in fact, acting in such capacity and agrees that he/she has read these terms and conditions and understands the policies of Imerman Angels laid out herein.    


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