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2023 Power in Pink 5K/1mile
Pink Tea 2023
Breast Cancer Run and Walk
In October We Wear Pink
Sponsors
Resources
Contact
Blog
2023 Power in Pink 5K/1mile
Pink Tea 2023
Breast Cancer Run and Walk
In October We Wear Pink
Sponsors
Resources
Resources
Cancer Resources
Intermountain Cancer Center -- Cedar City
Camp Kesem - Summer Camp for Kids
Application for Assistance from Power in Pink
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Name
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Address
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Email
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Phone
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Date of Diagnosis
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Stage/Type:
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What Assistance Do You Need? Why?
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By signing this form, I hereby acknowledge that I am a current breast cancer patient and have identified areas of need and am requesting assistance while I undergo breast cancer treatment. I understand that any assistance received will not exceed $250 in value. I further acknowledge that by providing the information on this application form, I will be contacted by a Power in Pink- Iron County representative to facilitate the approval process and receive any requested assistance, and I agree to absolve Power in Pink-Iron County of any liability related to this process.
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