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.
Recipient's Date of Birth*

MonthDayYear
Recipient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Diagnosis*

MonthDayYear
Ethnicity*

American Indian or Alaska NativeAsainBlack or African AmericanHispanic or LatinoWhiteOther
How would you describe your current employment status? *

Employed full-timeEmployed part-timeSelf-employedUnemployedStudentOther
Do you have any dependents who rely on your financial support? *

Yes, I have children who rely on my supportYes, I have family members who rely on my supportNo, I do not have dependentsOther
Anticipated Use of Funds *

MedicalBasic NeedsChildcareTransportationOther
Stage of Breast Cancer Diagnosis *

Stage 0Stage 1Stage 2Stage 3Stage 4
Type of Breast Cancer*

Ductal Carcinoma in Situ (DCIS)Lobular Carcinoma in Situ (LCIS)Invasive Ductal Carcinoma (IDC)Invasive Lobular Carcinoma (ILC)
Subtype of Breast Cancer*

Triple-negativeTriple-positiveHER2-positive, Hormone Receptor-negativeInflammatoryHormone Receptor-positive (ER+/PR+)Other
What is your primary source of health insurance coverage? *

Employer-sponsored health insurancePrivate health insuranceMedicaidMedicareUninsuredOther
How did you hear about Thriving Beyond Breast Cancer? *

Healthcare provider referralOnline searchSocial MediaWord of mouth (friend/family)Other
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.

Cancelof
**Please not that your application will not be considered if supporting documentation is not provided**
Signature of Applicant

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