Cowboys Against Cancer Grant Submission

Cowboys Against Cancer Online Grant Submission
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FINANCIAL ASSISTANCE FOR CANCER PATIENTS

A Service of Cowboys Against Cancer, a Wyoming Non-profit Corporation

OBJECTIVE

The goal of Cowboys Against Cancer is to raise funds for disbursement to Sweetwater County residents diagnosed with cancer. The disbursements shall be given to cancer patients to assist with expenses of obtaining necessary medical treatment.

POLICY FOR FINANCIAL ASSISTANCE

Cowboys Against Cancer is committed to assisting as many Sweetwater County residents as possible who are diagnosed and being treated for cancer. Therefore, at the beginning of each calendar year, based on available funds, Cowboys Against Cancer establishes a disbursement limit for any individual applicant per treatment year. To be eligible to receive a disbursement from Cowboys Against Cancer, the following conditions must be met:

1.       The applicant must be a resident of Sweetwater County for at least six months.

2.       The applicant must provide written documentation of a cancer diagnosis by the treating physician.

3.       The applicant must be receiving medical treatment for the cancer diagnosis that requires travel by the applicant outside of Sweetwater County, Wyoming, or the applicant must be receiving medical treatment for the cancer diagnosis within Sweetwater County.

4.       Upon approval by Cowboys Against Cancer, each applicant may receive a maximum of Three Thousand Dollars ($3,000.00) once within a twelve-month period, measured from the date of the approval. Eligible applicants whose treatment requires travel outside of Sweetwater County for treatment will be awarded a grant of Three Thousand Dollars ($3,000.00). Eligible applicants receiving treatment within Sweetwater County will be awarded a grant of One Thousand Five Hundred Dollars ($1,500.00). A recipient may apply for additional funds one year after the original date of approval by Cowboys Against Cancer as long as actual cancer treatment is continuing up to a maximum lifetime limit of three (3) annual grants.

PROCEDURE FOR ASSISTANCE

1.       Complete and submit an Application for Assistance to Cowboys Against Cancer.

2.       Applications must be accompanied by a signed letter from the treating physician, on the physician’s letterhead, stating the type of cancer diagnosed, the specific treatment prescribed, and stating the applicant is required to travel outside of Sweetwater County for this treatment or that the applicant is receiving the treatment in Sweetwater County.

3.       Cowboys Against Cancer will review the Application. If additional information is required, the applicant will be notified.

4.       Applicants meeting eligibility criteria will be notified in writing of the receipt of an award of financial assistance. Please allow a minimum of 4-6 weeks for processing and disbursement by Cowboys Against Cancer volunteers. Requests for immediate assistance are not granted.

5.       Recipients may use funds from Cowboys Against Cancer as the recipient deems appropriate.

REAPPLYING FOR FINANCIAL ASSISTANCE

If treatment continues beyond one year from the original date of approval of financial assistance or if cancer treatment becomes necessary at a later date, recipients may reapply for financial assistance one year from the date of receipt of the most recent grant from Cowboys Against Cancer up to a maximum lifetime limit of three (3) annual grants. The application for continued benefits must contain a signed letter from the treating physician stating that the type of cancer and the specific treatment required
ELIGIBILITY REQUIREMENTS FOR FINANCIAL ASSISTANCE

1. The applicant must be a resident of Sweetwater County for at least six months.

2. The applicant must provide written documentation of a cancer diagnosis by the treating physician.

3. The applicant must be receiving medical treatment for the cancer diagnosis that requires travel by the applicant outside of Sweetwater County, Wyoming, or the applicant must be receiving medical treatment for the cancer diagnosis within Sweetwater County.

4. Upon approval by Cowboys Against Cancer, applicants receiving treatment outside Sweetwater County may receive a maximum of Three Thousand Dollars ($3,000.00) once within a twelve-month period, measured from the date of the approval, or One Thousand Five Hundred ($1,500.00) for eligible applicants receiving treatment within Sweetwater County. A recipient may apply for additional funds one year after the original date of receipt of the most recent grant from Cowboys Against Cancer up to a maximum lifetime limit of three (3) annual grants.
Applicant's Name*

First NameLast Name
Date*

MonthDayYear
Date
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Home Phone:

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Length of Time You Have Resided in Sweetwater County:*
Work Phone

Area CodePhone Number
Employer:
Contact Person (Other than Applicant)
Phone Number of Contact Person

Area CodePhone Number
Treating Physician*
Phone of Treating Physician*
Address of Physician*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I Am Receiving Treatment (Check One)*

In Sweetwater County. I have attached written documentation from my treating physician on the physician's letterhead stating the type of cancer that has been diagnosed, the treatment prescribed, and stating that the applicant is receiving the treatment in Sweetwater County.Outside Sweetwater County. I have attached written documentation from my treating physician on the physician's letterhead stating the type of cancer that has been diagnosed, the treatment prescribed, and stating that the applicant is required to travel outside of Sweetwater County for this treatment.

Grant Application

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Cowboys Against Cancer Grant Form Upload

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Physician Letter

Applications must be accompanied by a signed letter from the treating physician, on the physician’s letterhead, stating the type of cancer diagnosed, the specific treatment prescribed, and stating the applicant is required to travel outside of Sweetwater County for this treatment or that the applicant is receiving the treatment in Sweetwater County
Physician Letter Upload

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I hereby consent that the medical records requested and provided may be made a part of my application for assistance to Cowboys Against Cancer. I further consent that my treating physician shall furnish to Cowboys Against Cancer any additional information concerning my health or physical condition requested by Cowboys Against Cancer or its officials. I understand that my application cannot be processed until I have submitted all required documents to the address shown on the top of this application.

By signing below, I certify that this request has been made voluntarily, that I have read and understand this application, and that the information given above is accurate to the best of my knowledge.
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First NameMiddle NameLast Name
Date*

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Date
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Grant Application

Physician Letter