Jiles Jewels Grant Intake form

Jiles Jewels Grant Intake form

ATTENTION: Please do not submit this form without your physician referral or Case Manager letter. Patients must reside in the following counties: Duval, Baker, Clay, St. Johns, and Nassau counties. Patients can only receive one grant per 12 month cycle. Grants are subject to availability, need assessment, and the discretion of Jiles Jewels.
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
E-mail
example@example.com
How did you hear about us?*
Please indicate Ethnicity

HispanicNon Hispanic
Please indicate Race

WhiteBlackAmerican Indian or Alaskan NativeAsian or Pacific IslanderOther
Number of people in your household
Please select your household income below:
Referring Physician/Case Worker Name

First NameLast Name
Referring Physician/Case Worker Phone Number
Please enter a valid phone number.
Diagnosis
Date Diagnosed (must be diagnosed in the last 24 months and be in active treatment (i.e. chemotherapy, radiation, surgery, infusion therapy, etc)*
Upload Physician referral letter on provider's letterhead. Must include your name, date of birth, date diagnosed, diagnosis of breast cancer and summary of current treatment. Please ensure letter is signed by the physician.

Cancelof
Enter your PayPal address. This will be used for distribution of funds if you are approved. Please note if you do not list your PayPal, it could delay the processing of any funds you may be granted.
Terms and Conditions:

1. Acceptance of Terms By submitting your information to Jiles Jewels, you acknowledge that you have read, understood, and agree to these Terms and Conditions. If you do not agree, please do not submit your information.

2. Eligibility To be eligible to receive assistance, you must:

Be a patient diagnosed with breast cancer in the last 24 months and in active treatment (Note: Active treatment is defined as chemotherapy, radiation, surgery, infusion therapy, etc)

Provide accurate and truthful information.
Consent to the collection, processing, and use of your information as outlined in these Terms.

3. Information Collection and Use By submitting your request, you authorize Jiles Jewels to collect and store your personal information, which may include but is not limited to:

Full name
Contact details (email, phone number, mailing address)
Medical condition details relevant to grant qualification
Financial information to assess need for assistance
Your information will only be used to assess eligibility, provide support services, and communicate with you regarding your request.

4. Confidentiality and Privacy Jiles Jewels is committed to protecting your privacy. Your information will not be sold or shared with third parties without your consent, except as required by law or for the fulfillment of your request.

5. No Guarantee of Grant Assistance Submitting a request does not guarantee receipt of financial assistance. Grants are subject to availability, need assessment, and the discretion of Jiles Jewels.

6. Use of Grant Funds Grant funds are intended solely for living expenses, including but not limited to rent, utilities, groceries, and transportation costs. Funds may not be used for medical expenses, personal loans, or non-essential expenditures.

7. Accuracy of Information You are responsible for ensuring the accuracy of the information provided. Jiles Jewels is not responsible for any issues arising from incorrect or incomplete information.

8. Limitation of Liability Jiles Jewels is not liable for any direct, indirect, incidental, or consequential damages arising from the submission of your information or receipt (or non-receipt) of grant assistance.

9. Changes to Terms and Conditions Jiles Jewels reserves the right to modify these Terms at any time. Any updates will be posted on our website, and continued submission of information constitutes acceptance of the updated Terms.

10. Contact Information If you have any questions or concerns about these Terms, please contact us at: jilesjewels@gmail.com

11. Patients must reside in the following counties: Duval, Baker, Clay, St. Johns, and Nassau counties.

12. I hereby grant permission to Jiles Jewels Inc. to use photographs and/or videos or likeness of me to edit, copy, exhibit, publish, or distribute in news releases, online, and in other communications related to the mission of Jiles Jewels Inc. I waive any right to inspect or approve the finished product wherein my likeness appears. Additionally, I waive any right to any form of compensation related to the use of photos/videos used in any of the above; and furthermore, hold Jiles Jewels Inc harmless from any claims or cause of action that may occur from my heirs or any representative in the future acting on my behalf .

I HAVE READ AND UNDERSTAND THE ABOVE RELEASE. I AFFIRM THAT I AM AT LEAST 18 YEARS OF AGE,

AND/OR HAVE OBTAINED THE REQUIRED CONSENT OF ANY LEGAL GUARDIAN(S) AS EVIDENCED BY

SIGNATURE(S) BELOW

By submitting your information, you acknowledge that you have read and agreed to these Terms and Conditions.
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