First Name
Last Name
Email
*
Organization
*
Organization Phone Number
*
Organization Address
*
Please complete the following information for the primary contact of your organization.
Contact First Name
*
Contact Last Name
*
Contact Email Address
*
Contact Phone Number
*
Additional Contact First Name
*
Additional Contact Last Name
*
Additional Contact Email Address
*
Additional Contact #2 First Name
*
Additional Contact #2 Last Name
*
Additional Contact #2 Email Address
*
What county/state/region does your organization cover?
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What is your organization's web address?
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Facebook account (if applicable)?
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Twitter account (if applicable)?
*
Are you a 501c3?
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Yes
No
Do you collect monetary or in-kind donations for your organization?
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Yes
No
What is your organization's stated mission?
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What services does your organization provide?
Support Group
Other Support Services
Education and Outreach
Financial Assistance to Survivors
Survivor Kits or Bags
Survivors Teaching Students
Attend Health Fairs
Work with Health Care Professionals
Advocacy
Financial Support for Research
Woman to Woman
If you provide other services that are not listed above, please list them here.
*
If you selected "financial assistance to patients" please explain.
*
What fundraising activities does your organization engage in?
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What are some of your organizational goals for 2023?
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How can OCRA be helpful to you?
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Anything else we should know?
*
Submit