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* 1. Name

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* 2. Pronouns (ie: they/she/he/xe)

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* 3. Company

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* 4. Address

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Country

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* 9. Email Address

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* 10. Phone Number

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* 11. Birth Year

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* 12. How do you identify in terms of race/ethnicity? Please select all that apply

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* 13. How do you identify in terms of gender?

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* 14. How did you hear about Brushes with Cancer?

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* 15. If you heard about the program through a friend or family member, please let us know who referred you.

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* 16. Have you participated in Brushes with Cancer previously?
 

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* 17. If yes, in what program or what capacity did you participate?

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* 18. Important Definitions : At Twist we identify survivors as anyone that has heard those three words "you-have-cancer" as you have survived that life changing experience. It is not about remission, cure, in treatment or out of treatment. Previvors are genetically predisposed to cancer and caregivers are individuals who are primary caregivers to individuals touched by cancer.

How do you identify? 

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* 19. If you are a previvor, please indicate your predisposition.

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* 20. What was the date of diagnosis (es) if relevant?

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* 21. What is your disease site? If you are a caregiver, what is the disease site of your loved one? Please check all that apply.

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* 22. If you have more than one disease site, please indicate any additional sites below.

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* 23. Do you have inherited cancer susceptibility? If so what kind? Please select all that are relevant.

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* 24. If you identify as a caregiver, has your loved one died?

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* 25. Where have you or your loved one received medical treatment?

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* 26. Please include the names of you or your loved ones medical team (oncologist, surgeon, radiologist, nursing staff, etc.) if you are willing to share that information.

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* 27. Why are you interested in participating in the program?

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* 28. What is your "twist on cancer?" Please share your lessons learned and big picture takeaways? (250 word minimum)

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* 29. Are you comfortable sharing your story?

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* 30. What is your preferred method of communication?

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* 31. I have participated in mental health counseling, psychotherapy, support groups, or other organizations/professional relationships to support me with my diagnosis/caregiving needs.

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* 32. If yes, where, and what was the nature of the support?

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* 33. My support system is mostly made up of: 

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* 34. I am in remission.

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* 35. My disease is chronic.

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* 36. Brushes with Cancer is currently looking to secure participants in the program. If you would like to nominate a potential candidate as an inspiration, artist or member of our host committee please include their name, email and possible role in the program.

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* 37. I understand I am responsible for connecting with my artist a minimum of 6 times over the course of our work together.

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* 38. Do you anticipate any barriers to participating in Brushes with Cancer, such as ADA accommodation needs,  financial concerns, language barriers, etc.?

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* 39. I feel disconnected from the world around me.

Strongly Agree Strongly Disagree
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i We adjusted the number you entered based on the slider’s scale.

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* 40. Even around people I know, I don't feel that I really belong.

Strongly Agree Strongly Disagree
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i We adjusted the number you entered based on the slider’s scale.

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* 41. I feel so distant from people.

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i We adjusted the number you entered based on the slider’s scale.

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* 42. I have no sense of togetherness with my peers.

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i We adjusted the number you entered based on the slider’s scale.

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* 43. I don't feel related to anyone.

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i We adjusted the number you entered based on the slider’s scale.

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* 44. I catch myself losing all sense of connectedness with society.

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i We adjusted the number you entered based on the slider’s scale.

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* 45. Even among my friends, there is no sense of brother/sisterhood.

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i We adjusted the number you entered based on the slider’s scale.

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* 46. I don't feel that I participate with anyone or any group.

Strongly Agree Strongly Disagree
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i We adjusted the number you entered based on the slider’s scale.

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* 47. Do you anticipate undergoing any major life changes or significant stressors which may overlap with the Brushes with Cancer Program timeframe that may or may not impact your participation in the program?

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* 48. As part of an ongoing effort to strengthen the impact of our programs, we may collect and analyze participant responses to program applications and evaluations. When analyzing responses, we are interested in trends in our data, rather than the responses of any particular person, and therefore responses will be de-identified for the purpose of data analysis. If you prefer that your responses not be included in data analyses, please check below. Please select Yes if you wish to include your de-identified responses and select No if you wish to not include your responses in future studies.

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