Nadine Whitlock HayesLegacy Fund view policies and guidelines Please enable JavaScript in your browser to complete this form.Name *FirstLastDate of Application *Date of Birth *Address *City, State, Zip *Phone *Email Address *Number of adults in household and relationship to you *Number of children (under 18) in household and relationship to you *Place of EmploymentOther Household Member's Place(s) of EmploymentApproximate Date of Breast Cancer Diagnosis *Doctor's NamePlease Check Any Treatment Types That May ApplyChemoRadiationSurgeryImmunotherapyEndocrine TherapyDate of TreatmentDo You Have Medical Insurance (including Medicare, Medicaid, or Private Coverage?)YesNoIf yes, please list provider.If yes, does your insurance cover prescriptions?YesNoUnsureEstimated Monthly Household Income (list all sources from those living in household - wages, unemployment, disability, other retirement, social security) *Liquid AssetsValue of Other Assets (home, equity, cars, land, etc.)HousingRentMortgageOtherPlease explain how your cancer diagnosis has affected your financial situation. You may include specific information about your monthly expenses and/or debts. *Please briefly describe request for funds, including your top 3 priorities for type of assistance you request (housing, utilities, food, transportation, medial bills, personal/household items). *Dollar Amount Requested *Please list other sources of assistance being sought/ received so that we may appropriately provide referrals.Please provide name and contact information for anyone you authorize us to communicate with regarding your application (such as treatment team members, social worker, relatives, people/business to whom you owe money).How Did You Hear About Pink-4-Ever?Please type your full name, which represents you have read this form completely and agree to the disclaimer/ release below. *Submit
