Brushes With Cancer Application Application Information Page1 / 4 25% of survey complete. Question Title * 1. First and Last Name Question Title * 2. Email Address Question Title * 3. Mailing Address (please include your country of residence) Question Title * 4. Age 18-25 26-34 35-44 44-50 51-58 58-65 65-72 73-80 Question Title * 5. Cell Phone: Question Title * 6. Have you participated in Brushes with Cancer? Yes No Question Title * 7. How did you hear about Brushes with Cancer? Question Title * 8. Please select which Brushes with Cancer Program you are interested in participating in. Chicago 2015 Tel Aviv 2015 Toronto 2015 Michigan 2015 Other: Question Title * 9. Have you or a loved one been touched by cancer? Yes No If so, when? Question Title * 10. How do you identify? Survivor Pre-vivor ( genetically predisposed to cancer but not yet diagnosed) Caregiver Artist Question Title * 11. Brushes with Cancer requires a four month time commitment for both the subject and artist. During this time the person touched by cancer will share their journey with the artist who will be charged with creating a unique piece of artwork that is reflective of that journey. We require that participants either meet regularly in person, on the phone or via skype in order to build a meaningful relationship. Please acknowledge that you are willing to commit the time and effort necessary to participate in this program. Yes No Next