Adopt A Hospital Sign-Up

By completing the information below, you make the first step to adopting healthcare facilities in your area. Once you fill out your contact information and the information about your adopted facilities as fully as possible, you will receive your materials in the mail within one to two weeks. This package will also include a "YSC in Action" volunteer button. We encourage you to wear this when distributing materials and show your pride as a member of the YSC team!

  Personal Contact Information

If you have previously registered, please to prepopulate your information.

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Name:

 

 

   

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City/State/ZIP:

 

    

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Question - Required - By entering today's date below, you are committing to disseminate to the above facilities the educational materials that will be sent to you by YSC.




 
Question - Not Required - Have you been diagnosed with breast cancer?


 
Question - Not Required - If yes, were you diagnosed at age 40 or under?


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