Jacob Way Application for Support and Initial Needs Assessment

1
What is the Patient's Name? * This field is required.Patient's Name
First Name and Last Name
2
What is the patient's name? * This field is required.
First Name
Last Name
3
What is the patient's gender? * This field is required.
Please Select
Please Select
Male
Female
N/A
4
What is the patient’s D.O.B.? * This field is required.
Date
Month
Day
Year
5
What is the patient’s race* This field is required.
Please Select
Please Select
White
Black or African American
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
6
What is your Address? * This field is required. EXAMPLE: 1234 Maple Street, Apt. 123, Memphis, Tn 12345
0/125
Huge
Large
Normal
Small
Ok
Ok
7
What language do you speak? * This field is required.
8
What is your address?* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
9
What is your phone number? * This field is required.
Area Code
Phone Number
10
What is the Guardian's Name? * This field is required.
First Name and Last Name
11
What is the guardian's name? * This field is required.
First Name
Last Name
12
What is the guardian’s email address* This field is required.
example@example.com
13
What is your Marital Status? * This field is required.Married, Single, Widowed or Divorced.
14
Marital Status* This field is required.
Single
Married
Divorced
Widowed
15
What is your total household size? (Parents + Children ) * This field is required.Under the age of 18 and/or disabled
16
What is your annual household income? * This field is required.
17
What is your social workers email address? * This field is required.
example@example.com
18
What is your social worker’s phone number? * This field is required.
Area Code
Phone Number
19
What is your child’s Pediatric Oncologist name?
20
What is the name of the hospital or clinic child is receiving care from? * This field is required.
21
What are your needs at this time? (rent, groceries, gas, household bills etc. )* This field is required.
22
Do you have a life insurance policy on any of your children?* This field is required.
YES
NO
23
Would you like to receive mental health support services and/or resources for any of the family members? (therapists, support groups, self-care workshops etc.)* This field is required.
YESNO
24
Do you have a life insurance policy on any of your children?* This field is required.
YESNO
25
Would you like to receive mental health support services and/or resources for any of the family members? (therapists, support groups, self-care workshops etc.)
26
How did you hear about Jacob Way Organization? * This field is required.
27
Agreements* This field is required.Please check all boxes to agree with terms and authorizations for application.
I understand that my personal information will not be published or shared with the public or a third party without my permission. Personal information Is defined as your home address, phone number, email address, and application status.
I agree to give Jacob Way Organization authorization to contact my social worker.
I agree to the release of my child’s health information to Jacob Way Organization from the social worker limited to doctors name and contact information, cancer diagnosis, date Of diagnosis and treatment plan.
I agree to receive emails from Jacob Way Organization for application status updates, newsletters and support resources.
The Information provided on this application is accurate and true to the best of my knowledge.
I agree to provide feedback on the Care Package or Financial Assistance by completing the feedback survey or a written testimonial. Your feedback will help us improve our services and create even better experiences for our clients. We kindly request that you consider: **1. Sharing a photo of the care package once it has been received. **2. Providing feedback on your overall experience with the care package or financial assistance including any specific items that stood out to you. Your participation will not only help us to offer more services but also assist others who are considering our services in the future.
Photo Release Statement : I hereby grant Jacob Way Organization permission to use photos/videos of me received from me/taken of me for promotional purposes and funders reporting without compensation. I release them from any liability arising from such use.
I understand that all support provided is dependent on the funding available to the organization at the time I apply for assistance.
28
SignatureBy Signing this form , you agree that the information provided on this application is true to the best of your knowledge and understand that incomplete applications will not be processed.
Should be Empty: