MBC Support Group Registration - Inheritance of Hope

Are you diagnosed with metastatic breast cancer?

Yes

Please provide the information. *

This group is not the best fit for you at this time.
Please feel free to explore our other Hope@Home™ Group options and reach out to
Allie@InheritanceOfHope.org
if you have any questions.

Page 1:
APPLICANT INFORMATION

First Name * Please provide the information. *

Last Name * Please provide the information. *

Date of Birth * Please provide the information. *

Gender * Please provide the information. *

E-Mail * Please provide the information. *

Phone Number * Please provide the information. *

Street Address * Please provide the information. *

City * Please provide the information. *

State * Please provide the information. *

Zip * Please provide the information. *

How did you hear about Inheritance of Hope? * Please provide the information. *

Have you/your family utilized/participated in any other services with Inheritance of Hope?
If so, which ones?
(Check all that apply)

Legacy Retreat®

Hope@Home™ Weekend

Annual Legacy Event

Hope@Home™ Group

Hope@Home™ App

Page 2:
FAMILY INFORMATION

Our mission is to inspire hope in young families, with children 18 or under,
facing the loss of a parent to a life-threatening illness.

Which applies to your family? *

I have been diagnosed with a life threatening illness.

-Diagnosis and how long have you been diagnosed:

My spouse/partner/parent is diagnosed with a life-threatening illness.

-Diagnosis and how long have they been diagnosed:

My family has already experienced the loss of a loved one.

-Loved one's relationship to you
-Date of Death
Please provide the information. *

Do you have children?

Yes

If so, how many children do you have and how old they are?

Parent/Guardian Info
(if applicable)

First Name Please provide the information. *

Last Name Please provide the information. *

Date of Birth Please provide the information. *

Phone Number Please provide the information. *

E-Mail Please provide the information. *

Same address as me

(If not, please provide information below)

Street Address Please provide the information. *

City Please provide the information. *

State Please provide the information. *

Zip Please provide the information. *

Page 4:
Group Registration

Support, through resources and relationships, for navigating challenges unique to MBC. Open to individuals and/or their caregiver with a MBC diagnosis.

What is one word (or a phrase) that would describe how you/your family are currently coping? * Please provide the information. *

What do you hope to gain by attending a Hope@Home™ Group? * Please provide the information. *

Any other information that would be helpful for our group facilitators to know about how we can best come alongside you? (optional)

Page 5:
ACKNOWLEDGEMENTS

I understand the purpose of Hope@Home™ Groups is to encourage a confidential and safe place for connection and shared experiences. The purpose of groups is not to provide counseling or therapy, but rather offer support through resources and relationships.

I agree *

You must agree to the term. *

By registering for this group, I give permission to Inheritance of Hope to photograph, film, and/or record and use those materials to encourage more people to enjoy this valuable resource.

I agree *

You must agree to the term. *

Inheritance of Hope trained volunteers may contact me directly to offer encouragement and on-going support outside of group meetings.

I agree (Optional)

Please provide the information. *

Programs

CONNECT

Resources

GIVE