Financial Assistance

Apply For Assistance

At Support Sisterz, we understand the financial challenges that come with battling cancer. Let us help ease your financial burden so you can focus on healing.

How It Works:
• Answer a few questions
• Upload your verification of diagnosis
• Someone from our outreach team will contact you as soon as possible
• Need immediate emotional support? Call us at 951-809-9256
• You can also find support in our Survivor Sisterz online community by clicking the "online support group" option under our assistance tab.

You don’t have to face this alone—let us support you.

Tell us about yourself

* Indicates required field

First Name *

Last Name *

Email *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of diagnosis *

Are you currently in treatment? *

Yes No

Where are you receiving treatment? *

What type of cancer were you diagnosed with? *

Breast Cancer Metastatic Breast Cancer Gynecological Cancer Metastatic Gynecological Cancer

What is your treatment plan? *

Additional details about your diagnosis *

If you are no longer in treatment, please share your cancer history *

Are you currently employed? *

Yes No

If you are unemployed, is it due to cancer treatment? *

Yes No

How long have you been unemployed? *

Are you receiving assistance from any other organization? *

Monthly household Income *

How many people in your household? *

Do you have health insurance? *

Yes No

Name of insurance carrier *

How did you hear about Support Sisterz? *

Upload your completed verification of diagnosis here (this must be completed by your doctor) *

Max file size: 20MB

*** please note ***
if you are submitting your application without uploading your verification of diagnosis, we can provide emotional support, but cannot provide financial assistance until it is received.

I understand that completing the 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. I certify that all the information provided is true and correct.

Submit

Blank verification of diagnosis form
File Size:	128 kb
File Type:	pdf

Download File

If you aren't in need of financial assistance, but would like emotional support, click the link below.

Emotional Support