Positively Pink Support Award Application
Submit your request for financial assistance, wellness support, or care-related needs.
Thank you for connecting with The Positively Pink Foundation, Inc.As we officially launch our 501(c)(3) nonprofit on December 11, our first initiative—Positively Pink Hearts for the Holidays (PPH4H)—is dedicated to supporting mothers currently navigating breast cancer treatment or recovery.
Please complete this brief form so our team can understand your needs and determine how we can best support you during this season.
Section 1: About You
Name
First Name
Last Name
Mobile Phone:
Do you wish to be included on event updates via text?
Yes, please
No thank you
Email Address:
Address (only used for fulfillment of requests for assistance; confidential & never shared)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How do you prefer to be contacted?
Call
Email
Text
Best time to reach you
Morning
Afternoon
Evening
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Section 2: Your Breast Cancer Journey
What is your current status?
In active treatment
Recently underwent treatment (within 2 years)
Long-term survivor (more than 2 years post-treatment)
Types of Treatment (check all that apply)
Chemotherapy
Radiation
Surgical procedure
Hormone therapy
Other
To ensure we can provide assistance responsibly and equitably, The Positively Pink Foundation requires a brief verification letter from your treating physician confirming your current diagnosis or treatment status. This information remains strictly confidential. Are you willing to provide a medical verification letter from your treating physician or care team?
Yes, I agree to provide the verification letter
No, I am unable to provide verification at this time
If yes, how would you prefer to submit the letter?
Upload directly to this form (see next section below)
Email it to: connect@tppfoundation.org
Upload Medical Verification Letter
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Section 5: Photo & Media Consent
At times, The Positively Pink Foundation may share stories, photos, or videos to highlight our mission and inspire other families facing similar challenges. If you are comfortable, we kindly ask for your permission to use images or brief testimonials related to the assistance you receive.This is completely optional and will never affect your eligibility for support.
Do you give permission for The Positively Pink Foundation, Inc. to photograph or record you (photo or video) and/or share a testimonial for future promotional, media, or public relations use?
Yes, I give permission (By selecting “Yes,” I understand that these materials may be used in print, digital, or social media formats by The Positively Pink Foundation, Inc., and I release the foundation from any claims related to their use.)
No, I do not give permission
I’m open to discussing this further if needed
If yes, please select where you are comfortable being featured:
Photos
Videos
Written or recorded testimonial
All of the above
Section 6: Anything else you’d like us to know?
Feel free to share your story, immediate needs, or anything that helps The Positively Pink Foundation, Inc. serve you with compassion and dignity.
Section 7: Consent
I understand that submitting this form does not guarantee assistance, and that all information provided is confidential and used solely by The Positively Pink Foundation, Inc. to assess my needs.
Submit Request for Support
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