Thank you for registering to let us know you are a survivor or have/had a family member who had breast cancer and for sharing your story so it may inspire and reassure others with your strength and hope!

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1. Please provide your name

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2. Please provide your mobile phone number

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4. What is your street address?

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5. Which phase are you in?

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6. What is your name on Facebook?

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7. Which of these describes your connection with breast cancer?

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8. The Pink-a-Rita events in 2026 are Friday Oct 16 & Saturday Oct 17. If you have been personally impacted by breast cancer, please check all that apply

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9. When (what year) were you or your loved one diagnosed?

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10. If you have a family member impacted, please describe who it is and how you were impacted (skip if this does not apply)

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11. Please provide any information, insights or wisdom you have to share with others (e.g. how you were diagnosed, the treatment you did or are doing, things that helped you cope or were most beneficial etc).

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12. Please provide three words that best describe your experience with breast cancer

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13. Would you be willing to record a video that we can share with other LOL members and LMWS residents online or during the Pink-a-Rita weekend?

Thank you for your help and for sharing your story! Someone will follow up with you soon!

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