3 Little Birds 4 Life Support Application

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We have a few ways to offer support to a newly diagnosed recipient, or a recipient that just needs a little extra help. How can we provide some extra support?

• Teamwork- with a few of our team and a few of your team we can create a plan to help take some of the stresses out of your life. Do you need daily errand help? Do you need cleaning/organizing help? Do you need help with meals/cooking? Do you need help with kid school or activity transportation?

• Home Hub Organizing Journal by Paper Hugs- This write in journal will help all of those that are here to help you know how you run your daily life. What cleaning products you use, kid/pet routines and allergies, and “All the Things” of your daily life. Once you fill this out, people will know your preferences and how to help you best.

Your Name *

Your Email *

Your Cell Phone Number *

Your Address (Street, City, State, Zip)

Patient Nominee Name (If the patient isn't filling the form out)

Patient Nominee Email (If the patient isn't filling the form out)

Patient Nominee Cell Phone Number (If the patient isn't filling the form out)

Patient Nominee Address (If the patient isn't filling the form out)

What type of Support are you looking for? *

Teamwork

Journal

Both

Are you, or is your Nominee a cancer patient in the age range of 25-55? *

Yes

Patient's relationship to you? *

Type of Cancer and Stage *

How did you hear about 3 Little Birds 4 Life? *

Submit

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