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APPLY FOR ASSISTANCE

APPLICATION FOR GRANT ASSISTANCE

We are grateful to use our resources to help those in need. Please fill out the form below to be considered for grant funding.

FIRST NAME

LAST NAME

ADDRESS LINE 1

ADDRESS LINE 2

CITY/STATE/PROVINCE

POSTAL/ZIP CODE

HOME PHONE NUMBER

CELL PHONE NUMBER

EMAIL ADDRESS

CONFIRM EMAIL ADDRESS

PATIENT'S FIRST NAME

PATIENT'S LAST NAME

PATIENT'S DATE OF BIRTH

GENDER

ETHNICITY

MARITAL STATUS

RELIGION

LANGUAGE

PLACE OF BIRTH

DOES THE PATIENT HAVE HEALTH INSURANCE

Yes No

IF YES, PLEASE NOTE THE TYPE OF INSURANCE (SELECT ALL THAT APPLY)

Private Insurance Medicaid Medicare Medicare Plus Medigap Veteran's Administration Benefits Other (If 'Other', Please specify here)

I NEED FINANCIAL ASSISTANCE TO OFFSET THE FOLLOWING CANCER-RELATED EXPENSES: (CHECK ALL THAT APPLY)

Basic Living Expenses (Mortgage/Rent/Utilities/Food) Personal Items (Wig Services, Prosthesis Bras, Hats) Home Care (Nursing Services & Cleaning) Transportation Pain Medications Child Care Lymphedema Supplies Other

IS THE PATIENT EMPLOYED?

Yes No

NUMBER OF PEOPLE IN HOUSEHOLD

PLEASE LIST MEMBERS OF THE HOUSEHOLD (INCLUDING AGE/RELATIONSHIP TO PATIENT)

CHECKING/MONEY MARKET ACCOUNTS

SAVINGS/CD

IRA/403B/401K

STOCKS & BONDS

OTHER

TOTAL FAMILY ASSETS

PLEASE UPLOAD A COPY OF A LETTER FROM YOUR MEDICAL PROVIDER VERIFYING YOUR CURRENT BREAST CANCER TREATMENT. PROVIDING THIS INFORMATION WITH THE SUBMISSION OF YOUR APPLICATION WILL ASSIST IN EXPEDITING THE PROCESSING OF YOUR APPLICATION.

INFORMATION WILL BE REVIEWED BY THE DONNA M. SAUNDERS FOUNDATION AND WE WILL CONTACT THE APPLICANT. ALL INFORMATION IS CONFIDENTIAL AND FOR USE BY THE DONNA M. SAUNDERS FOUNDATION ONLY.

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