Financial Support

Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number *

(###)

###

####

Alternate Phone Number

(###)

###

####

Date of Birth *

MM

DD

YYYY

Marital Status *

Married

Single

Divorced

Widowed

Partner

Current Employment *

Employed

Retired

Disabled

Other

Employer's Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Employer's Phone Number

(###)

###

####

Are you currently able to work? *

Yes

No

If not, when do you anticipate returning to work?

MM

DD

YYYY

Are you receiving any of the following?

Social Security Disability

Disability

Unemployment

Workers Compensation

Veteran’s Benefits

SNAP Benefits

Do you have health insurance? *

Yes

No

Date of Cancer Diagnosis/Reoccurrence *

MM

DD

YYYY

Would you be interested in learning more about any of the following?

Thrive to Survive (We need help spreading the word to others)

Support Groups

Survivor Wellness Programs

How to support TTS: Planned Giving, Memorial Donations, Tributes, Bequeaths, Corporate Partners, Volunteering

Cancer Oncologist, Surgeon or Radiologist Written Verification *

Please request from your treating cancer doctor to provide you a letter verifying cancer diagnosis and treatment information. Specifically, we will need verification on type of cancer treatment you are receiving, treatment dates, as well as diagnosis date. Letter needs to be provided on official letterhead and hand signed by doctor. You should email this letter to pam@thrivetosurvive.org.

I agree to emailing the Written Verification Letter from my Provider

Proof of Residence *

A copy of your New York State driver’s license, state ID or a copy of bill sent to your residence in your name must be emailed to pam@thrivetosurvive.org.

I agree that I am a resident of Ontario, Wayne, Seneca, or Yates County and will send my Proof of Residence

Authorization of Release of Information/Notice of Privacy *

By clicking submit you hereby authorize Thrive to Survive (TTS) to contact any party for information directly related to this grant application and making a decision to approve or deny the financial grant for assistance. TTS will demonstrate respect for your confidentiality, privacy, and security. Records and information are protected against loss, destruction, tampering and unauthorized access or use.

I agree to the above statement.