Please fill out this form to register for the Shocking Pink Sanctuary or download the form to complete and return:

1) Tell us about yourself

First Name (required)

Middle Name

Last Name (required)

Street Address (required)

Suburb

City (required)

Phone (required)

Your Email (required)

Preferred contact method (required)
 Phone Email

2) Your referring healthcare practitioner (We may need to confirm your eligibility with your provider)

Healthcare Practitioner (required)

Healthcare Provider Organisation

Provider type* (General practitioner, medical oncologist, hospice, practice nurse etc.) (required)

Street Address (required)

Suburb

City (required)

Phone (required)

Email

 I confirm that I have received a diagnosis of breast cancer or secondary breast cancer when aged 20-45 years old in the last 5 years and I am a resident in New Zealand.

 I authorise the Shocking Pink Charitable Trust to verify the details set out in this application (including obtaining verification of my medical condition from my medical advisers), and that my nominated medical advisers are authorised to disclose this information to the Shocking Pink Charitable Trust.

Respecting your Privacy

The Shocking Pink Charitable Trust will keep your name and details on our database so that our Programme Co-Ordinator can contact you regarding your care and our services.

Information may also be used by the Shocking Pink Charitable Trust for planning, service development and research and to endeavour to ensure that the programme continues to fully meet the intended purposes for which it was established. We will not pass your details on to any third parties, except sufficient detail to our service providers so that they can authenticate you right to subsidised Shocking Pink Sanctuary Programme Services.

Questions or Comments?