Emotional Support

Application for Assistance

Support Sisterz provides emotional and financial assistance to women who live or work in Corona, Norco, Eastvale and surrounding areas battling breast and gynecological cancers.

We understand that your battle against cancer is not fought alone - it is a battle that the entire family unit must face. While Support Sisterz may not be able to be there during the rounds of chemo, we are here to ease the burden of financial stress if possible. Please complete and submit the below to apply for financial assistance.

Application for Assistance

* Indicates required field

Name *

First

Last

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Cancer Diagnosis: *

Are you currently undergoing treatment? If so, what is your treatment plan? *

Where are you receiving treatment: *

If you are no longer in treatment, please share your cancer history: (optional) *

What type of support are you interested in, financial, emotional or both? Please share a little of what your needs are: *

Do you receive any type of financial assistance from another organization? *

Are you currently working? If not working, is it due to your cancer diagnosis? *

Total household income? (optional) *

**Please download the verification of diagnosis form below, have your doctor complete the form and upload it with your application.** *

Max file size: 20MB

I understand that Completing this Application for Assistance does not guarantee the receipt of financial aid. I understand that the information I have provided above, or may provide in the use of services extended by Support Sisterz, may be shared with other parties for the purposes of assisting me. By submitting this application, I am authorizing Support Sisterz to use the information provided to secure and or pay for services on my behalf and I certify that all information provided is true and correct. *

Please click to acknowledge you have read and agree to the terms of the waiver.

Submit

support_sisterz_verification_of_diagnosis.pdf
File Size:	128 kb
File Type:	pdf

Download File