Pink Promise Form – CANCER STOMPERS

Pink Promise Application Form

Tell us a bit about yourself!

Full Name

Date of Birth

Street Address

Street Address 2

City

Zip Code

State

Phone No.

My Personal Story

If your wish is granted, do you consent to Cancer Stompers feature your story on our social media platforms?

Yes No

Instagram Username

Please provide 3 options so that we can ensure you receive a wish.

Wish requests within the following categories can be granted:

Comfort and Self-Care: Items to support your physical comfort and mental well-being.
(Ex. A soft blanket, a journal, soothing lotion, a massage or spa voucher, or a high-quality tumbler.)
Small Appliances: Appliances to help simplify daily tasks, especially around meal preparation.
(Ex. A mini-fridge, air fryer, slow cooker, blender, or microwave)
Entertainment: Items to provide a positive mental escape and entertainment.
(Ex. Headphones, puzzles, a karaoke machine, a gentle yoga mat, or board games)
Nourishment & Treats: Gifts that support your energy and comfort through nourishing foods and easy meals.
(Ex. A grocery or meal delivery gift card, a snack box, herbal teas, or a helpful cookbook)

Which category(s) are you requesting?

Comfort & Self care Small Appliances Entertainment Nourishment & Treats

Choice #1: What is your wish? (Be sure to put in order of preference and state your request clearly)

Choice #2: What is your wish? (Be sure to put in order of preference and state your request clearly)

Choice #3: What is your wish? (Be sure to put in order of preference and state your request clearly)

Please share a few sentences and tell us what these wishes would mean to you

REQUIRED: Applicants must have a healthcare provider complete and sign the form below in order to apply for the Pink Promise Program.

Click here to download Healthcare Provider Form

Healthcare Provider Form

Attestation

By submitting this application, I verify that the applicant has been diagnosed with breast cancer and is currently undergoing treatment or has undergone treatment within the past six months, and currently resides in United States. I acknowledge that wish grants are made at the sole discretion of Cancer Stompers and that submission of an application does not guarantee fulfillment, and I agree not to hold Cancer Stompers responsible or liable if my request is not selected. I grant Cancer Stompers and its authorized partners the irrevocable right to use my likeness, story, and any submitted information for any purpose, including but not limited to editorial, marketing, advertising, and promotional activities across all media formats. I attest that all information provided is true and accurate to the best of my knowledge and understand that falsification of any information will result in disqualification from the program. I further understand that all gifts are final with no returns or exchanges, that Cancer Stompers is not responsible for any damage to items during shipping, and that I should consult with my physician before using any products received.