Event Beneficiary Application

Event Beneficiary Application
About the Foundation:

The Denise Marie Flaherty Memorial Foundation was established with a goal of trying to help fund research to cure cancer and assist families struggling financially to fight this terrible disease. We understand and respect the courage it takes to ask others for help. When a loved one is in need, we would all do anything and everything to get them the help and medical attention that is necessary.

The DMF Foundation would like to be a resource for you in this time of need. We have seen how fighting cancer creates such an emotional & financial burden on families, and we hope to be able to alleviate some of that stress for as many families as we can. We would love to be able to help every family who applies, sadly, we know that is not possible. For those families who we are able to assist, we try to match our level of giving to their level of need. This application allows us to work with you to determine that amount. In summary, to ensure that the monies we secure through our foundation reaches those families who need help the most, this application is necessary.

If while completing this application you should have any questions or concerns, please do not hesitate to contact us. We are here to help in any way we can, and I will respond personally to any inquiries or questions you may have throughout this process.

Sincerely and respectfully yours,

Brian “Red“ Flaherty
President & Founder
DMF Memorial Foundation

brian@deniseflahertyfoundation.org
Applicant's Information:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Are you currently being treated for cancer?*

YesNo
Are you currently employed?*

YesNo
Do you currently have medical insurance?*

YesNo
Alternate Contact Information

In case the applicant can not be reached.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
Financial Information
Total Monthly Income (Family):

Total Monthly Expenses:

	Totals
Mortgage / Rent
Utilities
Car Payments
Cell / Internet
Household Expenses (Food, Etc.)
Other Expenses

Total Monthly Expenses:
Financial Impact of Cancer:
Proceeds From Fundraisers (Go Fund Me, Other Charity Events):
Total Unpaid Medical Bills (Your responsibility)
Total Recurring Medical Bills (Your responsibility)
Total Future Estimated Medical Bills (Your responsibility)
Please upload any income/disability pay stubs, mortgage statements, car payments, and copies of medical bills to this application. We don’t need every bill, but enough to assess the total medical debt to date and the overall financial impact

Cancelof
What is your immediate financial need? (Unpaid medical bills, past due mortgage or car payments, travel costs for treatments, etc.) What support are you requesting to help alleviate this financial burden?
Please be specific as to the dollar amount.
Applicant’s Story:
Tell us about you and your needs. Please share as much detail as possible regarding your diagnosis and the financial impact that cancer has created.
Are you willing to allow DMF to use your story in press, our website, social media, and in brochures, flyers, and cards?

YesNo
Because we are a grassroots organization, we require that each beneficiary be announced, so we are unable to keep the selected applicant(s) anonymous during our marketing efforts for each event. We respect privacy, but we believe in the power of prayer as well. At the DMF Memorial Foundation, “No One Fights Alone.” We hope you understand.
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Event Beneficiary Application

Applicant's Information:

Alternate Contact Information

Financial Information

Financial Impact of Cancer:

Applicant’s Story: