THE FIELD HOUSE CANCER FOUNDATION ASSISTANCE APPLICATION
Application Date
*
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Month
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Day
Year
Date
Applicant Information
Name
*
First Name
Last Name
Address
*
Phone
*
Format: (000) 000-0000.
Email
*
example@example.com
Date of Birth
*
/
Month
/
Day
Year
Date
Social Security #
*
Is the applicant under the age of 18?
*
Yes
No
Gender
*
Male
Female
Prefer not to answer
Race
Hispanic
Asian
African American
White
American Indian
Prefer not to answer
Native Hawaiian
Do you meet the eligibility criteria outlined by The Field House Cancer Foundation to receive assistance?
*
Yes
No
Employment Information
Employment Status
*
Employed
Unemployed
If employed what is the Name of the company
Name and contact information to your direct supervisor
May The Field House Cancer Foundation contact them?
*
Yes
No
Diagnosis Information
What is your diagnosis?
*
Are you currently undergoing a recommended treatment plan for your cancer diagnosis?
*
Yes
No
Current Treatment Plan
*
Start Date
*
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Month
/
Day
Year
Date
End Date
*
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Month
/
Day
Year
Date
Applicant Income and Expenses
Household Size
*
Do you have children under the age of 18?
*
Yes
No
Ages of children (ex- 2,17,5)
Are You currently disabled? If so, Permanently or Partial?
Permanently
Partial
Other
Current Yearly Income- (please include all income)
*
Monthly Expense Amounts- (Ex- Mortgage, electric, car note, childcare)
*
Have you ever received assistance through The Field House Cancer Foundation?
*
Yes
No
Are you committed to keeping the The Field House Cancer Foundation informed of any changes in your financial or medical situation throughout the financial assistance period?
*
Yes
No
Are you currently receiving financial assistance from any other organization? If so, who
*
Are there any additional circumstances or details you would like us to consider in the approval process?
Can you confirm that the information provided is accurate and up-to-date?
*
Yes
No
Authorized Representative
(someone we can speak to on your behalf ex. wife, adult child, mother)
Authorized Representative Information- Name, Address, Phone, Email, Relationship
*
Did your authorized representative fill out this form?
*
Yes
No
SignatureDate
*
Authorized representative signature
Date
*
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Month
/
Day
Year
Date
Continue
Continue
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