Working together so no one faces cancer alone. The Bay Area Survivors (BAYS) and Imerman Angels are partnering to ensure that you receive the one to one support you need. Upon completing this form, Imerman Angels will follow up with any questions, then match you with the best match in their database, given your needs. This match may or may not be a member in the BAYS community.

REQUEST CAREGIVER SUPPORT / BECOME A CAREGIVER MENTOR ANGEL

I would like to: 

Receive Support and Request a MentorGive support and Become a Mentor

What best describes you:

I am a caregiver to someone with cancerI was a caregiver to someone with cancer

CAREGIVER INFORMATION_____________________________________________________________

First Name: 

Last Name:

Address:

Apartment or Floor Number:

City:

State:

Zip Code:

Best number to reach you:

Email Address:

Gender:

MaleFemale

Date of Birth:

MM/DD/YYYY format. This will allow us to connect you with someone similar in age.

PATIENT INFORMATION_________________________________________________________________

Name of person with cancer:

Relationship to person with cancer: 

Please select... Spouse Parent Sibling Child Friend Other

Their gender:

MaleFemale

Date of birth of person with cancer:

MM/DD/YYYY Format. This will allow us to connect you with someone similar in age.

Type of Cancer:

Stage of cancer:

Please select... 0 1 2 3 4 NA/Unknown

Treatment status:

Please select... Newly diagnosed Currently in treatment Finished active treatment Living with cancer Other

Please provide any additional information to enable us to make the best possible match. 

Imerman Angels is a federally registered 501(c)(3) nonprofit organization.

205 W. Randolph, 19th Floor

Chicago IL 60606

Phone: 877-274-5529

Email: info@imermanangels.org