Gift In Kind Event - Eligibility Questionnaire

First Name

Last Name

Date of Birth

Phone

NOTE: Please use the same phone number, if filling out more than one form.

Verify/Retype Email

Zipcode

City/State

Have you been diagnosed with breast cancer?
(If no, you do not qualify for this program.)

Are you in remission or active treatment?

Do you have medical documents stating these dates (diagnosis date / remission date)? This is required.

Are you able to provide supporting documents as attachments with your application? This is Required.

Can you complete and upload the HIPAA Compliant Authorization (filled out by you)

How did you hear about UBCF?

Which team member did you speak with?