APPLICATION - MISSISSIPPI 2023

APPLICATION - MISSISSIPPI

Constance Cares for Cancer will present checks to families in need to help cover medical and personal expenses related to cancer treatments after the upcoming event. In order to be considered, each applicant will need to complete the following application. This application does not guarantee approval.
Name*

First NameLast Name
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Treating Physician Name*
Treating Physician Phone Number*
Please describe your current medical condition.*
How will these funds help you?*
I certify that the information that I've provided above is true and correct.

I understand that any assistance the Foundation may provide is limited to the terms and conditions established by the Foundation and that the Foundation reserves the right at any time and for any reason, without notice, to discontinue assistance.

I understand that I may be photographed, filmed, or videotaped in connection with my involvement with Foundation. I further agree that Foundation shall be the exclusive owner of all copyright and other rights in such media. I have carefully read this Waiver and Release of Liability and fully understand its contents. I am at least 18 years of age and I am competent to contract in my own name. Iam aware that this is a release of liability and a binding contract between myself and the persons and entities mentioned above and I sign it of my own free will. I understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing this Waiver and Release freely and voluntarily, and intend by my signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Signature*

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