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Voices & Facesof Breast Cancer SurvivorshipParticipant
Registration Form
SECTION 1: Basic InformationPlease complete the following
application. Do not leave any spaces blank.
Name:
Current Age: __________Age at Diagnosis: _________ Length of
Cancer Survivorship: ________
Address:
City/State/Zip Code: County:
Phone: Occupation:
Email Address:
American Cancer Society Services you have used:
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________________________________________________________________________________
Application continued on next page.
2010 marks the 10 year anniversary for the Voices & Faces of
Breast Cancer Survivorship
Campaign in the Coastal Empire. The campaign is a compelling
visual display of breast cancer
survivorship, as well as, a critical breast cancer education and
awareness tool. The display of largephoto storyboards includes
pertinent breast cancer facts and figures. The storyboards are
displayed in
prominent public locations during the months of October and
November. The campaign also consists
of a video portion of 30-second spots which air on WSAV (NBC
Affiliate) throughout the year.Longer spots will be posted on the
WSAV website. Participants of this project have a unique
opportunity to reach people of various communities and share
their stories of hope, survivorship and
victory over breast cancer! You never know your story may reach
one person whose life couldchange forever!
The 2010 Voices & Faces committee is seeking breast cancer
survivors with compelling stories
of hope and survivorship. Applications are due by Friday, May
28, 2010. Once applications have beenreceived, a review committee
will select 12 applicants for participation.
The production (including photography and videography) date is
scheduled for Saturday, July
17, 2010 at the WSAV TV studios on Victory Drive in Savannah.
Selected participants will be
assigned appointments times and will receive more information
about production. Please note, ifchosen, there is no alternate
production date scheduled.
The 2010 Voices & Faces campaign will be unveiled during the
Fashion Show and Luncheon
on Saturday, September 25, 2010. Survivors selected for the
Voices & Faces campaign participate asthe models featured in
the fashion show!
If you would like more information, call 912.355.5196.
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Your Story of Breast Cancer Survivorship
SECTION 2: Outline
These short answers are to help you gather your thoughts.
1. Describe your Occupation or Lifestyle before you were
diagnosed with cancer?
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2. When/How were you diagnosed?
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3. How did you feel when you were diagnosed?
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4. Who was the person (or people) that made the most difference
in your diagnosis, treatmentand/or recovery?
______________________________________________________________
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____________________________________________________________________________
5. Personal message to share with others about your cancer
journey:
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SECTION 3: Expand Your Story
Use this space to tell us more of your story. (Use only the
space given. Do not attach more paper.)
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SECTION 4: Production
Please read carefully:
** Voices and Faces production will take place Saturday,
July
17 in Savannah, GA at WSAV Studios (1430 E Victory Drive).Are
you willing and able to attend production? YES NO
** Voices and Faces products, such as posters, display boardsand
videotapes are property of the American Cancer Society
and WSAV and will not be given or sold to participants.
Please initial:
** Voices and Faces participants will be given the
opportunity
to participate as Models during the Voices & Faces
Fashion
Show and Luncheon. Are you interested in participating in
thisevent? (Answering NO to this question will not jeopardize a
candidates opportunity to be chosen
as a participant.) YES NO
** You are required to sign a legal release form at time of
production.
Send completed forms to:Voices & Faces Application
American Cancer Society6600 Abercorn Street, Suite 206
Savannah, GA 31405
Fax: 912.355.0955
Deadline for submission of applications is Friday, May 28,
2010.
