Full Name

Cell Phone

Email

Home Street Address:

City, State, Zip

Age

What type of cancer did/do you have?

When were you diagnosed?

What stage are you at?Just diagnosedIn treatmentIn remission

In your own words, what is Your story as a woman dealing with this diagnosis? how has it changed you?

What is some advice you would like to share with other women dealing with the same diagnosis?

Are you open to sharing your story and photo journey with me and the American Cancer Society of San Diego so it can help others?YesNo

Our sessions are all about empowering and uplifting women through beauty photography, are you open to allowing yourself to be vulnerable and playful?YesNo

I understand that the photographer and makeup artist’s time is being donated completely along with 3 complimentary portraits.YesNo

I am willing to sign a release so my images may be used by SMP and ACS for marketing, social media and promotions.YesNo

I understand that if any portraits or products are purchased beyond the 3 complimentary, I will be paying the regular price for what I select. By purchasing additional portraits and products, I will be helping pay it forward for the next cancer survivor’s session.YesNo