Faces of MBC Submission Form

Please complete this form to request inclusion on the Faces of MBC page. You must be a recent or current resident of the Pittsburgh area.

Name*
Age
Current city / municipality of residence
Names of children / grandchildren
Age at initial diagnosis
Please enter a number from 18 to 110.
Year of initial diagnosis
Treatments
My message to people outside of Cancerland
High quality photo to be added to our page*
Please upload a high quality photo of yourself to appear on the website. Please include your first and last name in the title of the file.
Your email address

We may contact you if we need more information.