For PRG| JOIN THE GIRLS

Upon submission and approval your information will be added to the PRG searchable database. This password protected database is used by members to search for other young women by zip code, diagnosis, surgeon and reconstruction type (and others). Thank you for joining!

Once approved, you will receive a welcome email and will be provided with the instructions necessary to begin searching.

Please complete the following questionaire to join Pink Ribbon Girls.

Email / Password
Email Address *
Password *
General Information
First Name*
Last Name*
Street Address*
City*
State*	-Please Select- Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming
Zip*
Home Phone Number*
Work Number
Cell Phone Number
Do you consider yourself a resident of 'Greater Cincinnati?'
Level of Education	-Please Select- Some High School HS Graduate Some College Associates Degree Bachelors Degree Masters Degree
Occupation
Marital Status*	-Please Select- Single Partnered Married Seperated Divorced Widowed
Race/Ethnicity	-Please Select- Caucasian African-American Asian Hispanic Other
	Click here to upload your photo
Birthdate*	-- January February March April May June July August September October November December -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
How did you hear about PinkRibbonGirls.org? (Include description below)	Member Flyer Advertisement Doctor Other
Describe your answer above (provide member name, etc)
Cancer Specifics
Type of Cancer	-- Breast Ovarian Other
Date of diagnosis*	-- January February March April May June July August September October November December -- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Age at diagnosis*	-- 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 60+
General/Breast Surgeon's Name*	Please Select None/Not Applicable Patrick Brophy Stephen Cleves Karen Columbus Boyd Crafton Michael Davenport Stuart Donovan Elliott Fegelman Semele Foundas Kevin Grannan J Michael Guenther Lydia Hernandez Ching Ho David Kirkpatrick Jay Logeman Dianne Runk Elizabeth Shaugnessey Donna Stahl Other Other
Oncologist's Name*	Please Select None/Not Applicable Rebecca Bechhold J Bhaskaran Cynthia Chua Robert Cody Randy Drosick Douglas Hawley Elyse Lower Mary Ellen McCullough Thomas Morand Michael Neuss David Waterhouse Randy Drosick Other Other
Plastic Surgeon's Name*	-Please Select- None/Not Applicable Jennifer Butterfield Michael Columbus Robert Hummel Gene Ireland Kurtis Martin Peter McKenna Henry Neale Richard Williams Other Other
Gynecologist's Name*
Other Physician's Name	Other Specialty
How was your cancer first detected?* i.e. self-exam, clinical breast exam, mammogram?	-Please Select- Biopsy/Lumpectomy BSE - Breast Self Exam Clinical Breast Exam Mammogram Self - accidental Spouse/Partner Other - Please Explain
	Other Detection Method
Did you experience any breast pain, tenderness, or discomfort prior to diagnosis?*	Yes No
If you experienced breast pain please describe the occurrence *
How much time passed between the initial detection and the actual diagnosis?*	Years 0 Years 1 Year 2 Years 3 Years 4 Years 5 Years 6 Years 7 Years 8 Years 9 Years 10 Years Months 0 Months 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 7 Months 8 Months 9 Months 10 Months 11 Months Days 0 Days 1 Day 2 Days 3 Days 4 Days 5 Days 6 Days 7 Days 8 Days 9 Days 10 Days 11 Days 12 Days 13 Days 14 Days 15 Days 16 Days 17 Days 18 Days 19 Days 20 Days 21 Day 22 Days 23 Days 24 Days 25 Days 26 Days 27 Days 28 Days 29 Days 30 Days
Staging*	Please Select Stage 0 Stage 1 Stage 2A Stage 2B Stage 2C Stage 3A Stage 3B Stage 3C Stage 4
Diagnosis*	DCIS - Ductal Carcinoma InSitu LCIS - Lobular Carcinoma InSitu IDC - Infiltrating Ductal Carcinoma Invasive Lobular Paget's Disease Inflammatory
Were there lymph nodes involved, and if so how many?*	Yes No 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15+
What was your Estrogen/Progestin Receptor status?*	-- ER/PR + ER/PR - Unknown
What was your Her2Nu status?*	-- Her2Nu + Her2Nu - Unknown
What types of surgery (if any) did you have? * Please check all that apply	No Surgery biopsy - Surgical biopsy - Core Needle biopsy - Stereotactic biopsy - Fine Needle Lumpectomy Port Placement Bilateral Mastectomy Single Mastectomy Radical mastectomy Simple mastectomy Prophylactic Mastectomy Sentinel Lymph Node Biopsy Axillary Lymph Node Biopsy
Did you have breast reconstruction? If so what type?	Yes No Tissue Expanders Tram Flap LD Flap DIEP Flap Bilateral Reconstruction Silicone Implants Saline Implants Nipple Reconstruction Areola Tattooing
Radiation Therapy*	Yes No Type -
Chemotherapy?*	Yes No Type -
Hormonal Therapy?*	Yes No Type -
Please list any other types of treatment
Have you or your family members undergone genetic testing for BRCA1 or BRCA2?*	Yes No
Have you taken part in any Clinical trials?*	Yes No
Family Details
Is there any history of breast/ovarian cancer in your family?*	Yes No
Do you have any siblings with breast cancer?*	Yes No
Spouse's Name
Do you have any children?* If so please indicate how many?*	Yes No      -- 1 2 3 4 5 5+
Child 1 - Name/Details
Child 2- Name/Details
Child 3- Name/Details
Child 4- Name/Details
Child 5 - Name/Details
Member Interaction Preferences
The Survivor Network is a searchable database of all Pink Ribbon Girls' members. However, Pink Ribbon Girls respects your right to privacy, if at this particular juncture in your life you would like to become a member and but remain anonymous to other members - please select "No" to the visible to others on the Survivor Network.question below. You can still volunteer for events, access the message board and newsletter archives but not access the database of other members and vice a versa.
Subscribe to Pink Ribbon Girls Email List?	Yes No
Visible to other members on the Survivor Network?	Yes No