APPLICATION FOR FINANCIAL ASSISTANCE
Date of Application________________
TELL US ABOUT YOURSELF
First Name: ________________________ Last Name_____________________________
Address: ___________________________ City:_____________ Province:____________
Postal Code: ________________E-mail Address:__________________________________
Home Phone # ________________ Bus Phone # _____________ Fax:_________________
Canadian Citizen: YES___ NO ___ Landed Immigrant: YES__ NO__ OTHER( explain):______
Marital Status________ # of Dependents and ages:________________________________
HELP US UNDERSTAND YOUR DIAGNOSIS
Diagnosed with Breast Cancer on (date)____________________ Type:________________
Where are you being treated? (Name of facility/hospital:___________________________
Treatment received to date: _________________________________________________
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Additional Treatment required:________________________________________________
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Family Doctor: _____________________________Phone Number ____________________
Oncologist’s name: __________________________Phone Number____________________
PLEASE HELP US UNDERSTAND YOUR FINANCIAL SITUATION
(fill this section if you are a first time applicant or if your situation has changed)
Are you receiving financial aid from the government or other sources?: YES____ NO____
if yes please Explain:_____________________________________________________
Your net monthly income $:_____________ Spouses monthly net income:$_____________
Total Net Family Monthly Income: $_____________
Monthly Mortgage/Rental Payment $__________
Groceries/Food $__________
Cable/phone/internet $__________
Utilities (Hydro/Water/gas) $__________
Car payment/loan $__________
Other Loan payment(s) $__________
Insurance $__________
Other $__________ Total Expenses:$________________
Total Income $_____________________
Less Total Expenses $_____________________
Net surplus/loss $_____________________
Please include all other income into home, such as disability income, spouse’s/partner’s income, rental income etc. Please give any other details or comments you feel are important. Please also explain if “other” was filled in:_________________________________________________
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PLEASE TELL US HOW THE KELLY SHIRES BREAST CANCER SNOW RUN/FOUNDATION CAN HELP YOU? (Please feel free to attach additional page(s) if more space is required):____
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Did you include any receipts with your application? YES___NO___ If “yes” how many?_______
Would you like to add any additional information?___________________________________
_______________________________________________________________________ _______________________________________________________________________
YOUR MEDICAL SUPPORT TEAM
(Please have your doctor/Nurse/Social Worker, Etc. Fill out this section)
Medical Diagnosis & Comments_________________________________________________
______________________________________________________________________________________________________________________________________________
I have read and reviewed this complete application and to the best of my knowledge can confirm that this applicant is currently undergoing Breast Cancer treatment and is in financial need for assistance.
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Signature of medical or social expert
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Please print your name & position clearly
AUTOGRAPH
(Applicant must sign and authorize release to confidential information)
I certify that the above information is accurate. I also understand that this information is to be used by the Kelly Shires Breast Cancer Snow Run/Foundation for the sole purpose of assisting me financially
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(signature of applicant)
PLEASE HELP US TO HELP OTHERS
How did you find out about our organization?______________________________________
How could we be more helpful?________________________________________________
Other Comments or suggestions?______________________________________________
CHECKLIST–THE FOLLOWING MUST BE INCLUDED WITH YOUR APPLICATION:
____ Current Notice of Assessment for yourself and spouse (if applicable)
____ Proof of Citizenship or landed immigrant status
____ Proof of other funding received
____ Receipts/Estimates
____ Mortgage/Rent Statement
____ Medical report supporting diagnosis
Kelly Shires Breast Cancer Snow Run
523 Elizabeth Street, Suite 101
Midland, Ontario L4R 2A2
TOLL FREE 1-877-436-6467 FAX (705) 528-0782
E-mail:info@breastcancersnowrun.org
www.kellyshiresfoundation.org www.breastcancersnowrun.org
“OFFERING FINANCIAL ASSISTANCE TO BREAST CANCER PATIENTS”