Friends Like Me™ Care Package

Do you know a woman in Pennsylvania who has been diagnosed with breast cancer within the last six months?  

Just complete the following form and we will send out a Friends Like Me™ Care Package to a survivor AT NO COST TO YOU OR THE RECIPIENT!  Each box contains important and timely information about breast cancer treatment and support from a variety of organizations such as the National Cancer Institute, Cancer Information Service and the PBCC. In addition, each box includes a pink ribbon pin, donated and complimentary gifts such as cosmetics and books. For more information, call Carol at 1-800-377-8828 x100 or e-mail carol@pabreastcancer.org.

If you are a healthcare professional, requesting a Friends Like Me™ care package for a patient, HIPAA regulations require that we obtain the patient's signature.  Please do not use the form below!  Click to download the authorization form, complete all the information, and fax it to us at 717-721-2585, and we will send the patient a care package. 

If you have any products you'd like to donate which would be appropriate to include in future Friends Like Me™ Care Packages, or you'd like to sponsor one or more boxes with a donation of $100 apiece, please email Kim at kim@pabreastcancer.org.  Thank you!

Testimonials

"(Receiving a Friends Like Me™ care package) meant that people do care.  There are people like me, in the same situation I am now in.  I enjoyed looking at all the nice surprises and was very surprised to receive this package so soon.  That means a lot knowing there are people out there for me that know what I am going through."  -Judith, Northumberland, PA

"It felt like a warm blanket or a great hug."  - Renee, Morton, PA  

"Upon receiving the care package, it felt like a wonderful Christmas gift!  A surprise!!  What excitement to have all these great tools just for me to use and an easy way to learn more about my diagnosis.  So, so helpful."  Dorothy, Camp Hill, PA

Fields marked with an asterisk (*) are required.

Recipient Information: Friends Like Me care packages have been carefully produced to address the needs of women diagnosed with breast cancer within the last six months.  The materials are designed to support the new patient in a timely manner during those critical first few months when she is dealing with her diagnosis and making decisions about treatment options.   Recipient must be a breast cancer survivor living in Pennsylvania, or one with a recent recurrence.  The diagnosis date must be within the last six months. Please do not request that a Friends Like Me™ care package be sent to anyone other than the survivor.  We need the survivor's address for our records. You may request a Friends Like Me™ care package for yourself.   We customize each care package according to the specifics of each recipient's situation.  The questions we ask below help us to do that.
Name*
Address* Please no P.O. Boxes
Address 2
City*
State*
Zip*
Phone Number
Birthday
Diagnosis Date*	(Use MM/DD/YYYY format)
Does the recipient have a partner/caregiver?	Yes No Unknown/Choose not to answer
Might a book for husbands/partners be beneficial?	Yes No Unknown/Choose not to answer
Is she currently receiving or does she plan to receive chemotherapy?	Yes No Unknown/Choose not to answer
Is she currently receiving or does she plan to receive radiation treatments?	Yes No Unknown/Choose not to answer
Is this a recurrence?	Yes No Unknown/Choose not to answer
Sender Information:
Name*
Address*
Address 2
City*
State*
Zip*
Phone Number*
E-mail Address*
Birthday
Is sender a Breast Cancer Survivor? Yes No
Comments	At times we have small items for children.  If you'd like us to include them, please let us know if the woman has children and their ages.
What is your relationship to the recipient?*
Verification Code: Please enter the verification code that appears above:

Friends Like Me care packages are provided by the PBCC with corporate support from:

AstraZeneca
Harley-Davidson Foundation
and
individual donors


THANK YOU!