The Janice Workcuff C. A. R. E. Legacy Form

The Janice Workcuff C.A.R.E.

Legacy Program

FORM

SUPPORTING

Houston, Texas and surrrounding counties only.

Chambers, Fort Bend, Harris, Liberty, Montgomery

The Janice Workcuff C.A.R.E. Legacy Program

(Cancer Awareness resource Encouragement)

Assistance Guidelines

The Janice Workcuff C.A.R.E. Legacy Program provides limited emergency assistance and resource referrals to individuals undergoing active breast cancer treatment.

All assistance is:

Based on the availability of funds
Reviewed on a case-by-case basis
Eligibility must be verified
Not guaranteed

Available Direct Assistance

When funds or gift cards are available, an approved client may receive one of the following:

Transportation assistance totaling up to $100, which will be provided through gas gift card.
A grocery store gift card totaling up to $100.

Clients may not receive both transportation and grocery assistance for the same approved request. The funds or gift cards available at the time of approval

Resource Referrals and Navigation on angelssurvivingcancer.org

ASC may also provide information, referrals, or connections to community organizations that may assist with:

Breast cancer medical co-payments
Breast cancer-related prescriptions
Utility bills, including electricity, water, and gas
Cell phone expenses
Additional transportation needs
Food and household needs
Life-skills education and other supportive services that promote stability, productive living, and quality of life

Providing a referral does not guarantee that another organization will approve or aid. Documentation

Applicantsare be asked to provide:

Proof of active breast cancer treatment verification
Applying or documentation does not guarantee approval.

Important Notice

The Janice Workcuff C.A.R.E. Legacy Program is supported by donations, grants, gift cards, and fundraising efforts. Assistance is limited and may be temporarily unavailable when funds or supplies have been exhausted. Angels Surviving Cancer, Inc. reserves the right to approve, deny, limit, or place a waiting period on any request based on eligibility, documented need, previous assistance received, and available resources.

Today's Date

MM-DD-YYYY

Are you able to attend at least one time ASC Monthly Membership meetings the 4th Saturday, 1–3pm –Location: 4600 Reed Road, St. Francis Xavier Church – Is transportation manageable? You will have Access to community resource, get Support from other survivors and medical Professional speakers

If no please explain how we can assist you to attend at least once

Full Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please let us know which services you are requesting assistance with

Have you received Janice Workcuff C.A.R. E. Legacy program from Angels Surviving Cancer, Inc. BEFORE

If other, Please tell us how we can assist.

Stage of Breast Cancer:

Please type unknown if stage of cancer is not known

Age at Diagnosis:

Are you currently in treatment

If yes, treatment dates:

Please list start date and finish date (even if it's a future date)

If yes, type/s of treatment:

Are you currently employed?

If no, please state reason:

Please type N/A if not applicable

Please list all sources of income:

Amount of request: $

Please list estimated amount of funds or service requested

Head of Household

Number of members in Houshold

Annual household income:

Please explain the circumstances creating a financial need at this time:

Is this a request for a bra or prosthesis only?

If yes, what size Bra do you wear?

If yes, do you have a physician prescription for bra or prosthesis?

Is this a request for a Thanksgiving or Christmas food Basket from Angels Surviving Cancer, Inc. ( includes Turkey and nonperishable food)?

Is this for Christmas clothes for children?

Is this a request for Christmas toys for a child or children?

If yes to the following two questions, Please provide each child's age and size:

Please type N/A if not applicable

Referred by:

Did the referring Organization give you any assistance?

Name of referring individual

First NameLast Name

Email of referring individual

example@example.com

Phone Number of referring individual

Please enter a valid phone number.Format: (000) 000-0000.

The Janice Workcuff C.A.R.E. Legacy Program PROFILE