Wicklund Warriors Application for Assistance

WICKLUND WARRIORS, INC.

FINANCIAL ASSISTANCE APPLICATION
- We are committed to providing crucial support to individuals who, despite maintaining financial stability before their diagnosis, are navigating temporary periods of unemployment during their treatment. Recognizing the significance of these transitional phases, we aim to offer financial assistance to bridge the gap for individuals and their families, enabling them to focus on their well-being without the added burden of financial strain.
- All Applicants Must:
  - Reside, and have maintained uninterrupted residency for 12 months in Albany, Columbia, Greene, Fulton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, or Washington counties.
  - Be a person having a confirmed blood cancer diagnosis from an accredited medical center referred to us by that institution's social worker or member of its medical staff. Signed by the patient's treatment center’s Clinical Licensed Advocate.
  - Signed and properly attested by the Patient/Guardian.
  - Be at or below an annual gross income of 500% of Federal Poverty Guidelines and demonstrate a substantial loss of income due to blood cancer diagnosis.
Applicant Information

If under 18, please complete as Guardian.
Name*

First NameLast Name
Date of Birth

MonthDayYear
Date
Age at time of Application*
Cell #

Area CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Have you lived at this address for 6 months or greater:*

YesNo
Parent/Spouse/Caregiver Information

The person that lives with you that helps with care.
Parent/Spouse/Caregiver Contact Information

First NameLast Name
Parent/Spouse/Caregiver Phone Number

Area CodePhone Number
Relationship to the Applicant
Blood Cancer Diagnosis Information
Applicants Blood Diagnosis/Subtype
Applicants subtype (if there is one)
Date of diagnosis you are currently being treated for:
What is your current treatment plan? How long will you be in treatment?
Relapse?

YesNo
If relapsed, when was the original diagnosis?
Date
Need a transplant?

YesNo
If yes, what type of transplant
If going for a transplant, when?
Where will you have your transplant?

Dana FarberSloan Kettering Cancer InstituteAlbany Medical CenterOther
Do you have other major medical issues hindering your recovery?

YesNo
If yes; explain:
Do you smoke?

YesNo
Employment Information

If applicant is a minor, enter caregiver/guardian information
Currently employed?*

YesNo
If yes; list occupation, and employer. If unable to work based on treatment, what was your job?
Years employed at current job
At the time of diagnosis, were you:
Select one
After diagnosis, are you:
Select one
Financials

Combined household income. If currently unemployed due to treatment, what was your income prior to diagnosis?
Annual Household Income BEFORE Diagnosis:*
Applicants' current wages $/mo ‭BEFORE Diagnosis.*
Applicants' current wages $/mo ‭AFTER Diagnosis.*
Current combined monthly expenses:*
Parent/Spouse/Caregiver current wages $/mo.
Supplemental Security Income (SSI) $/mo.
Supplemental Security Disability Income (SSDI) $/mo.
Public Assistance

TANFSNAPFood StampsNoneOther
Combined Child Support $/mo.
Number of people in your household you are financially responsible for under 18:
Names and ages of household members:
What are your greatest needs?

Co-PaysTransportation CostsRent/MortgageFoodChildcareFoodUtilitiesOther
Elaborate on "greatest needs":
(rent, utilities, transportation, cell, food, etc.)
Upload any documents you feel would support "need"

Browse Files

Cancelof
Have you received monies from other charities? If so, which and how much from each?
Typically LLS and NYOH Foundation
Treatment Center Information
Treatment Center Location*
Prescribing Doctor*

First NameLast Name
Treatment Center Clinician*
Clinicians Email*
example@example.com
Clinicians Phone

Area CodePhone Number
Clinicians Signature

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Health Insurance Info
Do you have insurance?*

YesNo
Insurance Provider
Annual deductible Amount:
Please elaborate on how your diagnosis is impacting your life.
Applicant Attestation

By signing this form, I attest that the information provided on this form is true and accurate to the best of my knowledge. That any grant received will be used exclusively for needs identified on this application to maintain records of use. If requested, provide documentation of proper use of any grant and proof that the household’s annual income is equal to or less than 500% of the Federal Poverty Level.
- Reside, and have maintained uninterrupted residency for 12 months in Albany, Columbia, Greene, Fulton, Montgomery, Rensselaer, Saratoga, Schenectady, Schoharie, Warren, or Washington counties.
- Be a person having a confirmed blood cancer diagnosis from an accredited medical center referred to us by that institution's social worker or member of its medical staff. Signed by the patient's treatment center’s Clinical Licensed Advocate.
- Signed and properly attested by the Patient/Guardian.
- Be at or below an annual gross income of 500% of Federal Poverty Guidelines and demonstrate a substantial loss of income due to blood cancer diagnosis.
Signature of the Applicant

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Date*

MonthDayYear
Date
Parent/Guardian Name if Applicant is under 18

First NameLast Name
Social Media Usage

The Wicklund Warriors relies on generous donations from our supporters and sponsors. Allowing us to feature your cancer journey helps our donors understand to whom their contributions help. This connection is essential to our success and future funding. Therefore, we are asking permission to share your story on our social media platforms, events & other support collateral. We will never use your full name.
Facebook*

Yes, I grant permissionNo, I do not grant permission
Facebook Name
Instagram*

Yes, I grant permissionNo, I do not grant permission
Instagram Name
Email: info@wicklundwarriors.com

Mail: PO Box 11152, Loudonville, NY 12211

Learn More: wicklundwarriors.com

Facebook and Instagram: WicklundWarriors
Should be Empty:

WICKLUND WARRIORS, INC.

All Applicants Must:

Applicant Information

Parent/Spouse/Caregiver Information

Blood Cancer Diagnosis Information

Employment Information

Financials

Treatment Center Information

Health Insurance Info

Applicant Attestation

Social Media Usage