Your Story Foundation Medical Relief Grant

Your Story Foundation Medical Relief Grant Application

NOTE: To qualify for a Your Story Foundation Grant, the applicant must currently be receiving medical care for a cancer diagnosis and be able to show financial need. After review of your completed application we may require additional information. These grants are prioritized and intended for residents of Anacortes, WA. (Subject to Available Funds)
Date

MonthDayYear
Date
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.
Type of Cancer Currently Being Treated
Date Diagnosed
Name of Hospital/Cancer Care Center Where Medical Care is Being Provided
Name of Attending Physician
Phone # of Attending Physician
Please upload Attending Physician Signed Form

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Are you Employed?

YesNo
If Employed choose one

Part TimeFull Time
Name of Employer
Primary Caregiver Name (If Applicable)
If Caregiver is Spouse/Significant Other will they be taking time off from work?

YesNo
Do you have Dependents?

YesNo
If you have Dependents, please list names and ages
Are you applying for this grant for financial assistance or patient care assistance (self care treatment such as massage, spa treatment)?

Financial AssistancePatient Care Assistance
Do you have a support system locally? (friends, family) Please feel free to elaborate whether this is emotional support, financial support, or both.
How will this grant assist you? If applying for Financial Assistance, please indicate the amount requested what the funds will be used for. (for instance, food/gas/bills) If applying for Patient Care Assistance, please indicate the amount requested and the name of the company/service you'd like provided.
Have you previously applied for this grant? (one grant per year unless funds allow more)

YesNo
If yes, when did you apply?
How did you hear about this grant? (List name, address, phone # & relationship of the person who referred you.)
Your Story Foundation does not and shall not discriminate on the basis of race, color, religion (creed), gender, gender expression, age, national origin (ancestry), disability, marital status, sexual orientation, or military status, in any of its activities or operations. These activities include, but are not limited to, employment selection of volunteers and vendors, and the provision of grants and services.

Thank you for taking the time to apply for our grant. All completed applications will be reviewed on a weekly basis and applicant will be notified within 7-10 days of decision. Applications will be held on file for 90 days.
All information will be kept confidential.
Please type YES to acknowledge you read and agree to our Medical Authorization Release Form
located on previous page
Upload Signed & Dated Medical Authorization Release Form

Found on previous page
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ADDITIONAL COMMENTS
APPLICANT’S SIGNATURE (If 18 years of age or older): By signing below, you are stating that all of the above information is accurate.

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PARENT OR LEGAL GUARDIAN’S PRINTED NAME & SIGNATURE IS REQUIRED (If applicant is under the age of 18):

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Should be Empty:

Your Story Foundation Medical Relief Grant Application