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Box of Kindness Request Form

What is your first name?

What is your surname?

What is your email address?

Who are you requesting a Box of Kindness for?

What is their first name?

What is their surname?

Are they over 16 years of age?

Are they over 16 years of age?
A
B

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

Where are they receiving treatment?

Where are they receiving treatment?
A
B
C

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

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

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

Would you like to include a message in the Box of Kindness

We will print and pack your message into their Box of Kindness

How did you hear about ChemoHero?

Where shall we send your Box of Kindness?

This can be their address, or your address if you would like to give them their box. ( we have sent boxes to hospital wards before - but on occassions they have gone missing or been delayed getting to the recipient. )

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