Spierings Cancer Foundation Family Grant Application Step 1 of 4 25% Applicant InformationPlease complete the following for the Grant Applicant.Name* First Last Phone*Email* Your permanent home address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Please select the county of your permanent residence:* Brown Calumet Outagamie Waupaca Winnebago Other Have you received a Spierings Cancer Foundation Family Grant in the past?* Yes No We apologize for any inconvenience, but only permanent residents of Brown, Calumet, Outagamie, Waupaca, or Winnegamie are eligible for Spierings Cancer Foundation Family Grants.We apologize for any inconvenience, but grants are are given one time per family. Applicant Information, continuedGender* Male Female Age* Marital Status* Married Single Other How long have you been married? How many dependents live in your household?* Please list the ages of your dependents Household Financial Status & IncomeAre you currently working?* Yes No Do you expect to return to work?* Yes No If you are not currently working, when do you expect to return to work?* MM slash DD slash YYYY Has your ability to work been limited by your health or treatment?* Yes No Other If Other, please explain Has your household monthly income decreased as a result of your diagnosis or treatment?* Yes No If so, how much less is your household monthly income?* Are you currently retired?* Yes No Did you need to take an early retirement? Yes No Monthly Household IncomeMonthly Household WagesMonthly Government AssistancePlease enter the total of any unemployment compensation, Social Security, FoodShare, SNAP, EBT, etc. you receive each monthMonthly Retirement DistributionPlease enter the total of any retirement, pension, investment annuity or other disbursements you receive each monthMonthly Child Support or AlimonyPlease enter the total of any monthly child support or alimony you receiveMonthly DisabilityPlease enter the total of any monthly disability payments you receiveOther Monthly IncomePlease enter the total of any other monthly income you receiveYour Total Monthly Income Monthly Household ExpensesYour home* Own a Home Rent Other If Other, please explain What is your monthly mortgage or rent payment?What is your monthly utilities expense?E.g., electricity, heat, cable television, phone, etc.What is your monthly car payment?What is your monthly expense for food and groceries?What is your average monthly credit card payment?What is the total of any other monthly household expenses?Your Total Monthly Household ExpensesTreatment ExpensesAre you covered by health insurance?* Yes No What expenses are not included in your insurance plan? Deductibles Co-Pay Out-of-Pocket Please check all that applyWhat is your annual deductible?What is your co-pay amount?What is your out-of-pocket?Have you set up a monthly payment play with your healthcare provider for the above expenses?* Yes No If so, what is your monthly payment to your healthcare provider?* Your TreatmentWhat type of cancer are you battling?* Are you currently recieving treatment?* Yes No Other Where are you receiving treatment?* What is/was your treatment start date?* MM slash DD slash YYYY What is the estimated end date of your treatment?* MM slash DD slash YYYY What type(s) of treatment did you (or will you) receive?* Surgery Radiation Therapy Chemotherapy Other Please select all that apply.Please provide a little more information about your surgery.For example, if you had surgery, please tell us when you had your surgery.Please provide a little more information about your radiation therapy.*For example, if you had radiation therapy, please tell us how many treatments you had and dates.Please provide a little more information about your chemotherapy.*For example, if you had chemotherapy, please tell us how many treatments you had and dates.Please provide a little more information about your other treatment.*ReferralsWho referred you to the Spierings Cancer Foundation?* How did you learn about the Spierings Cancer Foundation?Your Cancer JourneyTell us your story, we want to hear about you and your family, and the things that worry you as you journey through your treatments.*For example: What you would do with the funds that the SCF grants you? What are the financial burdens that you worry about?Would you allow us to share your story publicly in our promotional materials? Yes No EmailThis field is for validation purposes and should be left unchanged.
