ACF Caregiver

Request Form
You do not have to deal with your loved one's anal cancer diagnosis and treatment alone! The mission of The HPV and Anal Cancer Foundation ("ACF") Peer Support Program is to provide personal connections to support anal cancer patients (we call them "Thrivers" rather than "Patients") and their Caregivers through the treatment process and beyond.
We are a unique resource for minimizing the fear and isolation of anal cancer. We seek to empower with emotional support and hope. We who have dealt with anal cancer are now committed to helping others celebrate the joy of life despite the battle with this cancer.
ACF's Peer Support Program is dedicated to help:
  • - Make the lives of anal cancer patients easier and of higher quality
  • - Create bonds on an emotional level
  • - Offer hope and inspiration
  • - Connect cancer patients with cancer survivors
  • - Answer the scary questions
  • - Teach family and friends how to support and understand what patients are going through
  • - Suggest useful resources for the patient, family, and friend
Peers do not give medical advice, but guide Caregivers to good sources of information for their Thrivers to discuss with their medical team; they listen, question, and help Caregivers understand what they are facing. Once you complete and submit this ACF Peer Caregiver Request Cancer Support Form, you will then be matched with a Peer Caregiver who has supported an anal cancer patient (Thriver"). We match you based on demographic information, cancer history, treatment, and any special requests of yours. All information is confidential and is never shared outside of the ACF with anyone except a matched peer, with the consent of the Caregiver.
We look forward to supporting you on your cancer journey.

Contact Information

Mobile
Home
Work
Mobile
Home
Work
(We are committed to your privacy and your email(s) will never be shared with an outside party other than your match without your permission)
Morning
Afternoon
Evening
Morning
Afternoon
Evening

Demographic Information

** We ask the following information to best match you with a peer. While most demographic questions are listed as optional, the more information you give the more effective the match. **
Y
N
Y
N

Caregiver Information

** The questions on this page are related to your caregiving experience. The more information you give, the better the match. **
Took my loved one to appointments
Provided physical support (i.e., helping with ostomy care, bathing and cleaning)
Spoke with physicians on behalf of my loved one
Helped my loved one to make medical decisions
Provided monetary support
Administered all necessary "at home" medications (i.e., pain killers)
Provided 24 hour care for my loved one
Other
Caregiver Pride
Residential Move
Missed work/wages
Job loss
Depression
Isolation
Stress
Change in relationship status (i.e., divorce, marriage or new/changed partner)
Other
Y
N
Y
N

Cancer Information - Part 1

** The following questions are related to the anal cancer thriver you cared for in order to match you with a fellow caregiver who had a similar experience. The more information you give, the better the match. **
Y
N
Y
N
Not Sure
Y
N
Not Sure
Chemotherapy
Wait and watch
Radiation
Alternative treatment
Clinical trial
Other
Surgery
5-fluorouracil (5-FU)
Mitomycin
Cisplatin
Cetuximab
Other chemotherapy drugs
Intensity modulated radiation therapy (IMRT)
Conformal radiation therapy (CRT)
Other radiation therapy

Cancer Information - Part 2

** The more information you give, the better the match. **
Allergic reactions
Burns
Infection
Skin irritation
Anxiety
Depression
Lymphedema
Urinary issues
Bone pain
Fertility changes
Neuropathy
Other side effects
Bowel mgmt
Hair loss
Sexual dysfunction
Y
N
Y
N
Y
N

Family

Caregiver Family
Some participants want to be matched with peers who also have kids. Please feel out the following if applicable.
Anal Cancer Thriver Family

Support Questions

Email
Phone
Video Chat
Text Messaging
In Person
I just want to speak with someone who understands what I'm going through
Experience with caregiving during and post treatment
Parenting and caregiving
Communicating with family and friends
Sex/dating/relationships/intimacy
Changes to diet
Working during my loved one's treatment
Complementary/Integrative therapies for my loved one's treatment
Adjusting to life after caregiving
Hospice and end of life care
Other

Terms of Use

I hereby confirm that the information provided in the above application is true and complete to the best of my knowledge. I understand that false information may disqualify me from consideration as a volunteer. My act of filling out the aforementioned form gives my consent to perform a background check. I will consider all information that I gain in my volunteer position to be confidential. I understand that my volunteer service will be terminated in an event of breach of confidentiality.
Y
N
The HPV and Anal Cancer Foundation ("ACF") is a not-for-profit organization that provides peer support assistance by connecting people who are currently fighting anal cancer (each, a "Thriver") with another individual who has faced anal cancer, in his or her lifetime (each, a "Peer Mentor"). Oftentimes, a family member or friend of a Thriver will seek support from ACF (each, a "Caregiver") and ACF gladly pairs them with someone else who has supported a person with anal cancer (each, a "Peer Caregiver" and together Thrivers, Caregivers, Peer Mentors, and Peer Caregivers, "Participants"). ACF's Peer Support Program gives each Thriver and/or Caregiver a chance to ask personal questions and express his or her worries and frustrations to, while receiving encouragement and support from, someone who is uniquely familiar with the challenges that Thrivers and/or Caregivers face.
Peer Mentors and Peer Caregivers are volunteer-mentors only and donate their time and energy to ACF and to the Thrivers and Caregivers with whom they develop contacts and relationships. Participants (Peer Mentors and Peer Caregivers or otherwise) are not, and are not part of the ACF network to act as, licensed medical or mental health/healthcare professionals. ACF's policy and express instruction to each Participant is that no Participant may recommend nor endorse any specific medical or non-medical tests, physicians, products, procedures, opinions, or other information to another Participant or otherwise give 'medical' advice to another Participant. Further, no Participant should ever construe anything relayed to him or her by any other Participant as medical advice, recommendation, or opinion. The sole purpose of the relationships set up through ACF is the offering and receipt of cancer support. Under no circumstance should any Participant solicit or offer professional, financial, medical, or other similar advice or assistance from or to, respectively, another Participant.
By answering the question below, you (a Participant) expressly indicate your understanding that the relationships established among any of the Participants are founded, and should be based solely on support (as indicated herein) and are not intended to be substitutes for professional treatment, advice, or diagnosis. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding any medical condition, whether it be yours or another person's. Please do not disregard professional medical advice you have received from your doctors or delay in seeking professional medical advice because of a communication with another ACF member (Thriver, Caregiver, Peer Mentor, Peer Caregiver, or any ACF officer, director, employee, or other volunteer) or because of something you have read on our website. The content of ACF's website (www.analcancerfoundation.org) is only to be read and/or used for informational purposes and is not intended to be a substitute for professional treatment, advice, or diagnosis. If at any time you have reason to believe you or a loved one may have a medical emergency or feel that you or a loved one need medical attention, please either call 911, go to the emergency room, and/or call your or their doctor, as appropriate, immediately.
We at the HPV and Anal Cancer Foundation are excited that you have found your way to our support network and look forward to the relationship that we will share with you.
PARENTS OR GUARDIANS OF MINORS (UNDER 18 YEARS OF AGE)
If the Participant is a minor (child under the age of 18 years) the undersigned parent and/or natural guardian or legal guardian of such Participant does hereby represent that he/she is, in fact, acting in such capacity and agrees that he/se has read these terms and conditions and understands the policies of the HPV and Anal Cancer Foundation laid out herein.
Y
N
Please complete the application and submit online, or mail the hard copy version to:


The HPV and Anal Cancer Foundation
P.O. Box 232 · New York, NY 10272
Or
The HPV and Anal Cancer Foundation
7 Albert Mews, Albert Road · London, UK N43RD


For more information or help with the application, call us at 646-593-7739 (US)
or 0-208-133-0739(UK). You can also email us at info@analcancerfoundation.org