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Twist Out Cancer Presents: Brushes with Cancer Northeast 2024 Inspiration Application
1.
Name
2.
Pronouns (ie: they/she/he/xe)
3.
Company
4.
Address
5.
City
6.
State
7.
Zip Code
8.
Country
9.
Email Address
10.
Phone Number
11.
Birth Year
12.
How do you identify in terms of race/ethnicity? Please select all that apply
American Indian or Alaska Native
Black or African American
Native Hawaiian or Pacific Islander
White
Hispanic or Latino or Spanish Origin
Not Hispanic or Latino or Spanish Origin
Mixed Race
Asian
Prefer Not to Answer
13.
How do you identify in terms of gender?
Female
Male
Transgender Female
Transgender Male
Gender variant/non-confirming
Other (OPEN)
Prefer not to Answer
14.
How did you hear about Brushes with Cancer
Participated previously
From a friend/family member
Web search
Facebook
Instagram
LinkedIn
Twitter
Other
15.
If you heard about the program through a friend or family member, please let us know who referred you.
16.
Have you participated in BWC or attended the celebratory event?
Yes
No
17.
If yes, in what program or what capacity did you participate?
18.
Important Definitions : At Twist we identify survivors as anyone that has heard those three words "you-have-cancer" as you have survived that life changing experience. It is not about remission, cure, in treatment or out of treatment. Previvors are genetically predisposed to cancer and caregivers are individuals who are primary caregivers to individuals touched by cancer.
How do you identify?
Survivor (anyone that has heard those three words "you have cancer").
Previvor
Caregiver
Supporter
Other
19.
What was the date of diagnosis (es) if relevant?
20.
What is your disease site? If you are a caregiver, what is the disease site of your loved one? Please check all that apply.
N/A
Brain cancer
Breast cancer
GI cancer
Gynelogical cancer
Genito Urinary
H&N cancer
Leukemia
Lung/chest tumor
Lymphoma
Melanoma
Multiple myeloma
Prostate cancer
Sarcoma
Spine tumors
Other
21.
Do you have inherited cancer susceptibility? If so what kind? Please select all that are relevant.
N/A
Brain cancer
Breast cancer
GI cancer
Gynelogical cancer
Genito Urinary
H&N cancer
Leukemia
Lung/chest tumor
Lymphoma
Melanoma
Multiple myeloma
Prostate cancer
Sarcoma
Spine tumors
Other
22.
If you identify as a caregiver, has your loved one died?
Yes
No
23.
Where have you or your loved one received medical treatment?
24.
Please include the names of you or your loved ones medical team (oncologist, surgeon, radiologist, nursing staff, etc.) if you are willing to share that information.
25.
Why are you interested in participating in the program?
Personal growth
Share my story with others
Inspire/help others
Receive support
Other
26.
What is your "twist on cancer?" (Lessons learned and big picture takeaways?)
27.
Are you comfortable sharing your story?
with your Artist
with the public who may attend the Brushes With Cancer gala
via Twist Our Cancer's social media account or your artist's social media account
All of the above
None of the above
28.
What is your preferred method of communication?
In-person
Phone
Email
Text
Video conference
29.
I have participated in mental health counseling, psychotherapy, support groups, or other organizations/professional relationships to support me with my diagnosis/caregiving needs.
Yes
No
Prefer not to answer
30.
If yes, where?
31.
My support system is mostly made up of:
Spouse/partner
Parents
Friends
Cancer community
Other
32.
I am in remission.
Yes
No
I am a caregiver and this does not apply to me
33.
My disease is chronic.
Yes
No
I am a caregiver and this does not apply to me
34.
Do you believe your employer would be interested in supporting Brushes with Cancer? If so please provide us with the name and contact information for the person(s) we should be in touch with.
35.
Brushes with Cancer is currently looking to secure participants in the program. If you would like to nominate a potential candidate as an inspiration, artist or member of our host committee please include their name, email and possible role in the program.
36.
I understand I am responsible for connecting with my artist a minimum of 6 times over the course of our work together.
Yes
No
37.
Do you anticipate any barriers to participating in Brushes with Cancer, such as ADA accommodation needs, financial concerns, language barriers, etc.?
38.
I feel disconnected from the world around me.
Strongly Agree
Strongly Disagree
Clear
39.
Even around people I know, I don't feel that I really belong.
Strongly Agree
Strongly Disagree
Clear
40.
I feel so distant from people.
Strongly Agree
Strongly Disagree
Clear
41.
I have no sense of togetherness with my peers.
Strongly Agree
Strongly Disagree
Clear
42.
I don't feel related to anyone.
Strongly Agree
Strongly Disagree
Clear
43.
I catch myself losing all sense of connectedness with society.
Strongly Agree
Strongly Disagree
Clear
44.
Even among my friends, there is no sense of brother/sisterhood.
Strongly Agree
Strongly Disagree
Clear
45.
I don't feel that I participate with anyone or any group.
Strongly Agree
Strongly Disagree
Clear
46.
Do you anticipate undergoing any major life changes or significant stressors which may overlap with the Brushes with Cancer Program timeframe that may or may not impact your participation in the program?
47.
As part of an ongoing effort to strengthen the impact of our programs, we may collect and analyze participant responses to program applications and evaluations. When analyzing responses, we are interested in trends in our data, rather than the responses of any particular person, and therefore responses will be de-identified for the purpose of data analysis. If you prefer that your responses not be included in data analyses, please check below. Please select Yes if you wish to include your de-identified responses and select No if you wish to not include your responses in future studies.
Yes
No
48.
Please upload a personal headshot
in this Dropbox folder.
