Support Friend Request Form

fill in and click submit to request a support friend

Your Name

Name of the person filling in this form

First Name

Last Name

Your Date of Birth

Date of Birth of the person filling in this form

MM

DD

YYYY

Your Email

Address of the person filling in this form

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Your Phone Number

Phone number of the person filling in this form

I am filling in this form

Please tell us who this Support Friend request is for

To request a Support Friend for myself

To request a Support Friend on behalf of someone else

Name and date of birth of person needing a Support Friend

If you are requesting a Support Friend on behalf of someone else, please write their name and date of birth.

Tell us your story

Please tell us why you (or the person needing the Support Friend) are requesting a Support Friend

Tumour Type (if known)

Date of diagnosis (if known)

Do you wish to subscribe to news and updates from us?

Yes, please

No, thanks

Additional information

Please feel free to add any further information that you think we need to know.

PRIVACY STATEMENT

We collect personal information from you, including information about your: name; contact information; location; interactions with us and reason for contacting us. We collect your personal information in order to provide information, support, guidance and advocacy. We keep your data secure and do not share it without your permission (except in rare extreme situations to avoid a person’s health or safety being endangered). You have the right to ask for a copy of any personal information we hold about you, and to ask for it to be corrected if you think it is wrong. If you’d like to ask for a copy of your information, or to have it corrected, please contact us at hi@braintumoursupport.org.nz, or 0272923337.

Support Friend Request Form

fill in and click submit to request a support friend

PRIVACY STATEMENT

Contact us

Office Address