Applicant Information
Name
*
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Demographic Information
Your responses to the following questions enable 4C Hope Cancer Support Organization to better serve communities equitably. All responses are kept private and secured and will not be used for discriminatory purposes.
What gender do you identify as?
Male
Female
Non-Binary
Other
Prefer not to say
Marital Status:
Divorced
Married
Partnership
Separated
Single
Widowed
Prefer not to answer
Have you ever served in the Military?
Yes
No
Prefer not to say
Race:
Asian or Asian American
Black, African American, or African
Hispanic, Latino, or Latina
Indigenous American, Native American, or Alaska Native
Middle Eastern or North African
Native Hawaiian or Pacific Islander
White or Caucasian
Prefer Not to Answer
Other
Household Information
Please list the total number of people living in your household including yourself
Please Select
1
2
3
4
+5
What is your housing situation?
Stable
Unstable
Prefer not to say
Total Net Monthly Household Income (after taxes)
*
Occupation/Employer
Employment Status
Full Time
Part Time
Unemployed
Retired
Medical Information
Medical Insurance Provider
Cancer Diagnosis:
*
Stage of Cancer:
Clinic/Hospital Name
*
Clinic/Hospital Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Oncologist name:
Additional Information
Please select your most urgent care related financial need (only select ONE):
*
Hospital visits/Parking/Gas
Travel and lodging to and from appointments
Prescription medications
Medical Equipment
Hospice care
Copays associated with cancer treatment
Utility bills
Mortgage/rent assistance
How did you hear about 4C Hope Cancer Support Organization?
Please tell us anything else you would like us to know:
Patient Release
I declare the information on this application is true and correct to the best of my knowledge. I understand that each application is reviewed on a case-by-case basis, and the final decision will be made by 4C Hope Cancer Support Organization's Committee. I hereby give my permission that this application and all information offered can be provided to 4C Hope Cancer Support Organization and discussed with my healthcare professional. I understand that all information reviewed is confidential.
Signature
*
Print
Save
Submit
Submit
Should be Empty: