The Foundation for Living Beauty | Become a Living Beauty

First Name *

Last Name *

Mailing Address 1 *

Mailing Address 2

City *

State *

Postal Code *

Date of Birth

Email *

The Foundation for Living Beauty uses email as our primary method of communication. Please be sure to add [email protected] to your address book to ensure we do not get sent to your spam or promotions folders. If you need to be contacted by a different method, please contact the Living Beauty office.

Home Phone

Cell Phone

Work Phone

Approximate Annual Household Income *

How many people are in your household? *

Has your cancer impacted your household income? *

Please select all that apply

How would you self-identify your ethnicity? (This question is solely for our own demographic program purposes) *

American Indian Asian/ Pacific Islander Black Latina White Mixed Ethnicity Other I decline to answer

Emergency Contact Name

Emergency Contact Phone

Emergency Contact Relationship

Doctor's Name

Doctor's Phone

We will only contact your doctor in case of emergency

What is your primary hospital?

Type of Cancer(s) & Stage *

Date of your most recent diagnosis? *

Year of your original diagnosis? (if different from your most recent diagnosis)

I am currently in treatment for cancer: *

Yes No

I am not NED (No Evidence of Disease), but have chosen not to seek treatment at this time:

Yes No

What treatments and/or procedures have you received? *

Date of Most Recent Treatment *

Please list the programs/organizations that provide you support regarding your cancer diagnosis as well as the type of support they provide:

As of today, what are your greatest physical and emotional needs?

Please rate how you feel about the following statements:

I feel spirited and empowered *

I have a strong support system *

I am connected to other women with cancer on a regular basis *

I feel isolated on my journey *

How did you hear about us? (If a specific person referred you to the organization, please list their name) *

Tell Us Why You Would Like To Become A Living Beauty? *

Participant Signature *

By clicking this checkbox you are digitally signing this application form and agreeing to the terms outlined in the release of liability and photo release forms.

» View Liability Release

Release of Liability:
By signing below, I agree that The Foundation for Living Beauty (FFLB) is in no way responsible for the safekeeping of any personal belongings while I attend any Living Beauty Events.

I understand that classes during the any events may be physically strenuous and I voluntarily participate with full knowledge that there is risk of personal injury (including death), property damage and/or other loss. On behalf of myself, my heirs, personal representatives and executors, I hereby release, discharge, indemnify and hold harmless The FFLB, its subsidiaries and affiliates, and their respective officers, directors, employees, volunteers and agents from and against any and all losses, liabilities, damages, actions, suites, demand or claims, of any nature or cause (each, a "Claim"), including costs and attorney's fees incurred by The FFLB in connection with such Claim, arising from damages or injuries which may be sustained or caused by me, directly or indirectly, in connection with my participation with The FFLB, whether or not caused by The FFLB or it's officers, directors, employees, or agents or otherwise.

Photo Release:
I grant FFLB the right and permission in respect of photographic portraits, pictures or videos that it has taken, to copyright the same, in its own name or otherwise; to use, re-use, publish, and re-publish the same in whole or in part, individually or in any and all media now or hereafter known, and for any purpose whatsoever, for illustartion, promotion, art, editorial, advertising and trade, or any other purpose whatsoever without restriction as to alteration.