Application for Medical Stipend for Cancer Treatment/Financial Hardship

Recipient's Full Name

First NameLast Name

Email

example@example.com

Phone Number

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

Recipient's Date of Birth

Recipient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Diagnosis

Ethnicity

How would you describe your current employment status?

Do you have any dependents who rely on your financial support?

Anticipated Use of Funds

Stage of Breast Cancer Diagnosis

Type of Breast Cancer

Subtype of Breast Cancer

What is your primary source of health insurance coverage?

How did you hear about Thriving Beyond Breast Cancer?

Please note that Thriving Beyond Breast Cancer requires supporting documentation to process and approve applications.

To complete your application, kindly attach the following proof of diagnosis and financial need:

Medical Record: Documentation that includes your diagnosis, treatment plan, and any ongoing medical care.
Letter of Recommendation: A letter from your primary healthcare provider or oncologist endorsing your application and verifying that the stipend is essential for your continued treatment.
Financial Statement: Qualifying documents may include: W-2 forms, Recent pay stubs, IRS Form 1099, Employer attestation, Social Security statement

File upload(s) must include all 3 supporting criteria listed above to be considered.

**Please not that your application will not be considered if supporting documentation is not provided**

Signature of Applicant

Note: All fields must be completed before signature field is activated.