Spierings Cancer Foundation Family Grant Application Step 1 of 4 25% Are you filling out this application for yourself or on behalf of someone else? Please select one of the following options:* For Myself For Someone Else If you are filling out this application on behalf of your child, please provide the child's information in the 'Applicant Information' section. Make sure to include your child's name and details where indicated, and include your information when asked about household details. 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 dependentsHousehold 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 explainHas 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 Wages*Monthly Government Assistance*Please enter the total of any unemployment compensation, Social Security, FoodShare, SNAP, EBT, etc. you receive each month. If you are not currently receiving monthly government assistance, please enter 0. Monthly Retirement Distribution*Please enter the total of any retirement, pension, investment annuity or other disbursements you receive each monthMonthly Child Support or Alimony*Please enter the total of any monthly child support or alimony you receive. If you don't currently receive child support or alimony please enter 0. Monthly DisabilityPlease enter the total of any monthly disability payments you receive. If you don't receive disability please enter 0. Other Monthly Income*Please enter the total of any other monthly income you receive.Your Total Monthly Income* Monthly Household ExpensesYour home* Own a Home Rent Other If Other, please explainWhat 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 Expenses*Treatment 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 receiving 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 treatment.*For example, if you had surgery, please tell us when you had your surgery. If you had radiation therapy, please tell us how many treatments you had and dates. If you had chemotherapy, please tell us how many treatments you had and dates.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?What is your greatest need right now? We want to help take one worry off your plate, so please share how you would use the grant funds.* Housing Food Medical Expenses Travel Utilities Other 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. Δ
