Assistance Application

I release authority to gather medical information and records requested as to my condition.*

The below information is true and accurate to the best of my knowledge.*

Electronic Signature (Type Name)*

Date*

GENERAL RELEASE AND TERMS OF ACCEPTANCE

The Englewood Area Cancer Foundation is a 501(c)3 nonprofit organization that offers financial assistance to individuals who meet the foundation’s eligibility criteria, based on the availability of funds and resources.
The Foundation is unable to pay medical bills, co-payments, credit card bills and does not provide cash grants directly to client. As funds are limited, all applicants are encouraged to create a plan for long-term support and utilize all community resources.
To qualify, an applicant must:
- Be a current resident in the State of Florida in one of the following zip codes (34223, 34224, 33946, 33947, 33981, 33921)
- Be actively receiving treatment from a Florida oncology practice
I understand that participation in the Englewood Area Cancer Foundation is voluntary and these benefits represent a humanitarian effort to provide financial support to patients who are battling cancer and experiencing financial difficulties. I hereby release, defend, indemnify, and agree to hold harmless The Englewood Area Cancer Foundation, its officers, directors, agents, sponsors, medical advisors, volunteers from all claims, demands, causes of action, present or future, whether known, anticipated or unanticipated, resulting from, arising out of, or incidental to my participation in the programs or benefits provided by The Englewood Area Cancer Foundation.

First Name*

Last Name*

Address*

City*

State*

Postal Code*

E-mail*

Phone Number*

Date of Birth*

Gender

Occupation*

Employer Name

Employer Phone #

Diagnosis Date*

Cancer Type*

Oncologist Full Name

Support Being Requested*

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