Survey - 2024 Catwalk for Cancer Care Model Nomination

2024 Catwalk for Cancer Care Model Nomination

Your Information

1. Field Is Required Name:

2. Field Is Required BMC Department:

3. Field Is Required Phone Number:

4. Field Is Required Email Address:

Nominee Information

5. Field Is Required Nominee Name:

6. Field Is Required Ethnicity (if known):

7. Field Is Required Approximate Age:

8. Field Is Required Gender:

9. Field Is Required Nominee Phone Number:

10. Nominee Email Address:

11. Field Is Required Nominee Mailing Address: (Maximum response 255 chars, approx. 5 rows of text)

Additional Information

12. Field Is Required Which type of cancer has this nominee been treated for?

13. If known, please provide whatever background information you can on the nominees' life, interests, hobbies, accomplishments, challenges, etc. We are seeking models with a compelling story.

14. Field Is Required Does the nominee participate in any cancer patient support services at BMC?

15. Field Is Required Why do you think this nominee should be a model in the Catwalk for Cancer Care?

16. Field Is Required What is your relationship with the nominee?

17. Field Is Required Are there obstacles that would prevent this nominee from participating in the event? This may include health, age, transportation, communication-related issues or the time commitment. Please explain.

18. Field Is Required Does the nominee have access to a computer, phone, or other technology that would allow them to participate in a virtual info session on Zoom?

19. Field Is Required Is this nominee also a BMC employee?

20. If so, please provide their department and job title. (Maximum response 255 chars, approx. 5 rows of text)