Individual Assistance Application

Individual Assistance Application
Name*

First NameLast Name
Age*
E-mail*
Sex*

MaleFemale
Ethnicity*

African AmericanCaucasianHispanicOther
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County*
Home Number*

Area CodePhone Number
Cell Number

Area CodePhone Number
Date of Birth*

MonthDayYear
Medicare*

YesNo
Medicaid*

YesNo
Insurance*

YesNo
Other assistance being received?*

YesNo
If yes, please list.
Name of Spouse/Parent/Guardian

First NameLast Name
Name(s) and age(s) of dependents
List any other household members
Household Financial Information

List all income of all household members. Proof of income is required through prior year tax return, copy of monthly support income (child support, SSI, Social Security, pension, etc) or two recent pay stubs.
Type of cancer/year diagnosed*
Primary treatment physician's name*
Treatment center address and phone number
Describe specific cancer assistance needed, duration, cost
Medications
Transportation needs
Distance from residence to treatment facility (miles/round trip)
Medical equipment
Other
Extenuating circumstances
I understand that by submitting this form, I am attesting to the fact that this information is accurate. I understand that I will need to provide a signed physician's letter.*

YesNo
Signature*
Should be Empty: