Recipient Nomination By making us aware of a person fighting cancer, you would have our service made available to them. Our awards include services offered by our volunteers as well as limited financial support toward the payment of a bill, groceries, gas, transportation, or medical needs, as well as special programs for the children in the household. If you would like to nominate someone to receive an award from the Breathing Room Foundation please fill out the form below. NOTE: This form must be completed by a member of the healthcare team. If you are not a member of the nominee’s healthcare team, please download and print the form so that it can be completed by the appropriate person. If you have any questions please call us at 215-277-1006 or email maryellen@breathingroomfoundation.orgHealthcare Involvment*I am a healthcare professional involved in the nominee's cancer care.I am not a healthcare professional involved in the nominee's cancer care and agree to print out the forms above.If you are not a part of the individual’s healthcare team, please have a nomination form completed by a healthcare professional (social worker, nurse, doctor, therapist). NOMINATION FORM Once the forms below are completed mail or fax them to: MAIL The Breathing Room Foundation P.O. Box 287 Jenkintown, PA 19046 FAX 888-852-6190 Also, please fill out the contact information below to be contacted by The Breathing Room in the future. Thank You!Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code County*BucksChesterDelawareMontgomeryPhiladelphiaPlease choose the county where the recipient resides.Phone*Cell/ Other PhoneDate of Birth* Age*Please enter a value between 0 and 110.Gender*MaleFemaleRace*White Non HispanicAfrican AmericanHispanicAsianOtherIf other please specify*Email (if patient does not have email use no@email.com)* Enter Email Confirm Email Email* Enter Email Confirm Email Type of Cancer*Diagnosis is:*NewRecurrenceMetastatic Disease?*YesNoUnsureStage of Disease if knownAny additional information that might help us to classify this patient's diagnosisDate of Most Recent Diagnosis* Doctor's Name* First Last Doctor's Phone*Is this family low-income?*YesNoThis information is important for grant purposes. Family InformationTotal number of people living in the household*Number of children living in the homePlease enter a value between 0 and 25.Ages of children living in the householdSpouse or Caretaker's Name First Last Relation to recipientPhoneReferred byReferred by Name* First Last Referred by Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Professional Affiliation*For example: What hospital or healthcare facility to work?Referred by Phone*Referred by Email* Relationship to Recipient NomineeComments*Please include any additional information that might help us in providing support to this patient.