Choose one grant quarter (select only one option- grants are paid over the course of 3 months): *
Please indicate which program you are applying for: *
Are you in active treatment? *
Active treatment is defined as the period after a positive diagnosis of breast cancer has been made (with a diagnostic biopsy), and during which therapies are being administered, including surgical procedures to remove the cancer (e.g., single, or bi-lateral mastectomy, lumpectomy, axillary dissection, or sentinel node biopsy), chemotherapy or radiation. Active treatment does not include reconstruction surgeries or long-term hormonal therapies.
Proof of Income/ Employement Status of Applicant *
All applicants must provide one (1) of the following proofs of income. If documentation cannot be provided, you may submit a written signed statement describing your income. Please circle what item of income you are including with this application.
W-2 statement
Three (3) most recent pay stubs
Last year’s income tax return
Written signed statement
YOUR STORY – Please share your breast cancer journey. This will not be shared unless approved in section E, but we will use your story to help make a decision of the financial assistance. Attach additional pages if needed.
AUTHORIZATION
If approved for the financial assistance, PINK “ME” asks for your permission to share your story with others to help raise public awareness of the organization, communicate to donors and community to support the cause, and inform breast cancer patients, healthcare providers, and others about the Organization’s services.
IMPORTANT: You do not have to authorize permissions, this will in no way affect your financial assistance status for the program.
I understand I have the right to revoke my authorization at any time by contacting PINK “ME” at info@pink-me.org or at the below address. Revocation will be effective upon receipt and affects disclosure moving forward and it is not retroactive. I understand that my approval or denial of permission will in no way affect the assistance provided to me by the Organization.
Yes I allow PINK"ME" to use: *
I understand that information disclosed may be subject to redisclosure and may no longer be protected by Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health (HITECH) Act.
I understand that PINK “ME” Organization owns all marketing and outreach materials as released by me, and I hereby release rights to these items. I understand I will not be compensated for the use of the released information. I have read and understand the terms of this release. I certify that I am of legal age, 18 years of age or older.
I understand that PINK “ME” ® may verify information by reviewing information and obtaining information from other sources to assist in determining eligibility for financial assistance or payment plans.
I affirm that the above information is true and correct to the best of my knowledge. I understand if the financial information I give is determined to be false, this may result in denial of financial assistance, and I may be responsible for and expected to pay for services provided.
IMPORTANT INFORMATION
Applicants selected in the financial assistance program(s) will be contacted via email from our financialassistance@pink-me.org
SUBMISSION DOES NOT GUARENTEE FUNDING
To help us with your bill payments and submissions, please provide the billing address or the necessary information for making online payments.
All bills must be submitted at one time; partial submissions will not be accepted.
If you have any questions, feel free to reach out. We're here to support you.
Submit
Thank you for submitting your application for financial assistance. Our committee will review and get back to you within 5 days. Please note that all approved grants are subject to funding and financial resources available. If we need more information, we will contact you. For any questions, please email us at financialassistance@pink-me.org .
