Request Support
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
If you play or are associated with a rugby club, please let us know which.
Who will be the recipient of the Support?
Myself
Husband
Wife
Partner
Mother
Father
Child
Teammate or Friend
If it is not for yourself, please tell us the full name of the recipient
With which cancer have you (or the recipient) been diagnosed?
At which stage (if known) is the cancer and what treatment is being received?
Please tell us more information about why you are applying for support from Rugby Against Cancer?
Have you received assistance from Rugby Against Cancer or another Charity?
Yes
No
If you answered yes, please provide details
Which type of Rugby Against Cancer Support would you like to request? If you would like to apply for more than one, please complete the form twice
Adult Support Kit Bag
Adult Support Kit Bag
Respite Break
Memory Experience
One-off Grant
Something Else
If you chose something else, please state what support you would like.
If you have selected Respite Break or Memory Experience - Please provide details of how you would like Rugby Against Cancer to support you (or the recipient) We can provide a voucher towards a Respite Break or a Memory Experience.
I confirm that the information in this form is correct and true, and I have provided the relevant information required to apply for support from Rugby Against Cancer.
I confirm
Rugby Against Cancer is 100% compliant with the General Data Protection Regulation (GDPR). To learn more about how we collect, keep, and process your private information in compliance with GDPR, please view our privacy policy on our website rugbyagainstcancer.com. This policy was last updated on 25/10/21 I am happy for Rugby Against Cancer to keep my information on file according to the charity's GDPR policy.
Yes
Submit
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