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Box of Kindness Request Form

What is your first name?

What is your surname?

What is your email address?

Are you over 16 years of age?

Are you over 16 years of age?
A
B

Are you currently receiving or about to start S.A.C.T?

S.A.C.T = Systemic Anti Cancer Treatment.
Our Boxes of Kindness are filled with items specifically designed to support individuals currently undergoing cancer treatment. If you are not currently receiving treatment, the contents may not be appropriate for your needs.
Are you currently receiving or about to start S.A.C.T?
A
B

Where are you receiving treatment?

Where are you receiving treatment?
A
B
C

If outside of North Devon, where are you having your treatment?

Which Box of Kindness would you like us to send you?

Which Box of Kindness would you like us to send you?
A
B

How did you hear about ChemoHero?

Where shall we send your Box of Kindness?

Address Line 1

Address Line 2

Town or City

County

Post Code

If you are able, would you like to help cover the cost of postage for your Box of Kindness?

We use Royal Mail and the cost to post a ChemoHero Box of Kindness is £7.05 (48hr Tracked).
If you are able, would you like to help cover the cost of postage for your Box of Kindness?
A
B