North Texas Honored Hero Application
First Name of Honored Hero
Last Name of Honored Hero
Relationship to Honored Hero
If parent of Honored Hero, please type name here [First Last]
Address Line 2
Daytime Phone Number
Evening Phone Number
Date of Birth [enter as 00/00/0000]
What is the best method to contact you?
Phone - Daytime
Phone - Evening
Honored Hero Diagnosis
Other [please specify]
Date of Diagnosis [enter as 00/00/0000]
Cancer Center/Hopsital where treated?
Honored Hero Current Status:
Did Honored Hero have a transplant?
Yes - Autologous (donor was self)
Yes - Allogeneic (donor was someone else)
Date of Transplant [enter as 00/00/0000]
How did you learn about The Leukemia & Lymphoma Society?
Additional Comments/Message to Participants:
I would like to be an Honored Hero for the following campaigns:
Team In Training
Light The Night
School & Youth / Pennies for Patients
Big D Climb
Not sure yet - please call me
Choose your level of Honored Hero involvement:
Share name, diagnosis and photo only
Share name, diagnosis, photo and story in PRINT
Share name, diagnosis, photo and story in print AND speak in public
I would like more information about other volunteer opportunities:
I would like more information about the speaker's bureau program (trained volunteers speaking on behalf of The Leukemia & Lymphoma Society in our communities):
Please share your story with us by supplying a 2-3 paragraph autobiography of your experience with cancer.
Please include a high resolution photo of the Honored Hero. (Please send jpg files only.)
Honored Hero Waiver
As an Honored Hero you will be added to our mailing list to receive research/treatment updates, information on upcoming educational programs and special events. Please carefully read the following disclaimer and sign below. I hereby authorize and permit The Leukemia & Lymphoma Society or its authorized agent, without compensation therefore, permission to photograph, publish, reproduce, record and use, with or without my name or the name of the person for whom I am the parent/guardian. This includes, but is not limited to, photographs, quotes and/or text, national Web site pages or audio/visual media of and/or by me or the person for whom I am the parent/guardian.
I release The Leukemia & Lymphoma Society from any and all legal liability that may arise from the release of information requested. I agree that all text made of and/ or by me or the person for whom I am the parent/guardian by or for The Leukemia & Lymphoma Society, shall be the exclusive property of The Leukemia & Lymphoma Society, which in its sole discretion may use this material as it sees fit in any medium or forum. By signing below you herby agree to the terms and conditions as described above.
(If under 18, signature of parent / guardian required.)
Indicates Response Required