Pink Helping Hand Application – New Applicant

1. APPLICANT INFORMATION

First Name

Last Name

Sex

Female Male

Date of Birth

Address

Street Number

City, State

Zip Code

Phone Number

Marital Status

Number of adults living in household

Number of minors living in household

2. MEDICAL INFORMATION

Medical Provider Name

Provider Office Phone Number

Provider Address

Date of Diagnosis

Current Treatment

3. SUPPORTING DOCUMENTATION

Proof of Identity Accepted formats: PDF, JPG, JPEG, or PNG

Proof of Breast Cancer Treatment or Diagnosis Accepted formats: PDF, JPG, JPEG, or PNG

4. APPLICANT STATEMENT & SIGNATURE

Sign

I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge. I understand that United Colors of Pink may request additional documentation to verify the information provided. 
I understand that submitting an application does not guarantee financial assistance and that assistance is subject to program eligibility, available funds, and United Colors of Pink's review process. 
I understand that providing false or misleading information may result in denial of assistance or the requirement to return funds received.

Signature

Printed Name:

Date

Authorization to Verify Information

I authorize United Colors of Pink, as necessary for the purpose of reviewing this application, to contact the medical provider, social worker, or other organization identified in this application to verify my diagnosis/treatment and information relevant to my request for assistance. 
I understand that I may withdraw this authorization in writing, subject to applicable legal requirements. Applicant Signature

Printed Name:

Date

Pink Helping Hand

Application for New Applicants