Information Form

Breast Cancer Survivors and Friends

Information Form

The information in this form will not be seen online, will not be given out to anyone other than the webmaster, and most definitely will NOT be sold to anyone. I, for one, hate SPAM!

We, the members of the Breast Cancer Survivor and Friends forum, decided to do this so that we have a way to contact members in case of absence, catastrophe (earthquake, tornado, etc.), as we do tend to worry about each other.

Name
Forum Name at BCSAF
Address
Country/State/Province/City
If other, where are you from?
Phone
Cell Phone
E-mail and/or Instant Messenger (List which IM, i.e. MSN, Yahoo, AIM)
Is there anyone that you would like to designate as an emergency contact in case we can't get in touch with you? If yes, please list name, relationship, and phone number.