Girl I Got Cancer Scholarship

Girl I got cancer, inc. Application Form
The Girl I Got Cancer, Inc. scholarship provides scholarships to fund the cost of wigs, co-pays, medications and egg freezing/retrievals for women fighting cancer.

Please read and follow the instructions carefully prior to submitting your application. Scholarships are issued on a rolling basis.
If selected, you will be asked for documentation to support the information you provide. Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please provide accurate information.
Full Name*

First NameLast Name
Birthdate*

MonthDayYear
Mobile No*
Format: (000) 000-0000.
Email *
Where the confirmation will be send to
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Wig (a wig or funding for a wig will be provided)Co-Pay AssistanceMedicationsEgg- Retrieval ProcedureMonthly Egg Freezing Cost
Occupation*
Gross Monthly Income (before taxes)*
SingleMarried
How many people are in your household?*
What type of cancer are you fighting?*
How would receiving this assistance impact your fight?*

0/300
Please upload your two (2) most recent paycheck stubs or most recent tax return.*

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Please upload a document evidencing your cancer treatment (appointment ledger, diagnosis records, letter from treating physician, etc.)*

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VIII. Applicant's E-Signature
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
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Girl I got cancer, inc. Application Form

VIII. Applicant's E-Signature