Team Shred
Funding Families Application Form
Shred Out Cancer is excited to invite your family to join our Funding Families program. The program provides monetary assistance to disease-affected families, in order to provide them with resources and support to continue their everyday lives as normally as possible
Please complete and return this form as soon as possible. The application process takes approximately 2 weeks. Once the form is processed, you will also be added to our Shred Out Cancer mailing list to receive information on upcoming events and other ways to get involved with the organization. If you have additional children with a medical condition that qualifies for the Funding Families program, please fill out additional Membership Forms.
CHILD’S INFORMATION
Child’s First Name: ________________________ Last Name: __________________________
Date of Birth: ______________________________ Sex: Male _______ Female ________
Diagnosis: __________________________________ Date Diagnosed: __________________
Hospital/Clinic: _________________________________________________________________
Family Doctor: _________________________________________________________________
Phone: _______________________________ Date of Last Treatment: ___________________
Current Medical Condition: ________________________________________________________
Is condition progressive? Yes ______ No _______ Cognitive Age: ________________________
Estimated # of hospital visits last year: _____ Estimated # of school days missed last year: ____
(Please exclude visits for common childhood illnesses)
PARENT/GUARDIAN INFORMATION
Parent’s First Name: _______________________ Last Name: ____________________________
Parent’s First Name: _______________________ Last Name: ____________________________
Address: ______________________________________________________________________
City, State Zip: __________________________________ County: ________________________
Phone: __________________________________ Phone 2: _____________________________
Email: ________________________________________________________________________
HOUSEHOLD MEMBER INFORMATION
Name (first and last) Relationship Sex Date of Birth
_______________________________________________M / F___________________________
_______________________________________________M / F___________________________
_______________________________________________M / F___________________________
_______________________________________________M / F___________________________
_______________________________________________M / F __________________________
_______________________________________________M / F___________________________
_______________________________________________M / F___________________________
Total # of members in household: _______
Household Income: ___ less than $20,000 ___$20,000 – $35,000
___ $35,000 – $50,000 ___ over $50,000
Number of Adults in Family: _________ Number of Children in Family: __________
PLEASE NOTE:
Upon review and acceptance into the Funding Families program, tax returns of the past 2 years will be necessary to finalize the application. Falsely stating financial information will result in termination of the application with possible legal action.
Tell us about your families’ hobbies, interests, etc.
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
REFERRAL SOURCE
Name: ________________________________ Title: __________________________________
Hospital/Organization: ___________________________________________________________
Phone: ____________________________ Email: _____________________________________
Date of Referral: ____________________________
Household Income: ___ less than $20,000 ___$20,000 – $35,000
___ $35,000 – $50,000 ___ over $50,000
Number of Adults in Family: _________ Number of Children in Family: __________
DEMOGRAPHIC INFORMATION (optional):
Shred Out Cancer seeks sponsors to help fund the Funding Families program. Some of these sponsors are interested in some information about the families we serve. We do not collect this information as measures for acceptance into the Funding Families program, but it would help us secure funding from some sources. Do not feel obligated to answer the following questions.
Ethnicity: ___ Alaskan Native ___ American Indian
- ___ Asian ___ Black/African-American
- ___ Hispanic/Latino ___ Pacific Islander
- ___ White/Caucasian ___ Other
Please return your completed application by mail, email:
Please return your completed application to:
Shred Out Cancer
ATTN: Joseph Kostecki
100 Barnegat Blvd S
Barnegat, NJ 08005
Shred Out Cancer is committed to protecting the privacy and the confidentiality of the personal information collected from our employees, families and volunteers. The information you provide will be used to deliver services and to keep you informed and up to date on the activities of Shred Out Cancer.
For Shred Out Cancer use
Name: _______________________________ Date: ___________________________
Approved/Enrolled: ___________________ Entered in DB: ____________________
Welcome Letter Sent: _________________ Date: ___________________________
For more information about Shred Out Cancer, please visit www.shredoutcancer.org.sd