Financial Assistance Application Form

Financial Assistance Application

Thank you for your interest in The Jill Foundation’s financial assistance program. Our mission is to provide financial assistance to hairstylists working in Orange, California who are affected by breast cancer. Grants are: Breast Cancer in one breast $2,500 or Breast Cancer in both breasts $3,500. Grants may be used for any financial need, including health care, rent, groceries, childcare, transportation, etc. To be considered for assistance, applicants must:

Be a hairstylist in the Southern California area.
Have been diagnosed with a form of breast cancer within the past year or have on-going breast cancer, which is subject to verification by your doctor.

Submit your completed application to The Jill Foundation at the mailing address above. If an application is incomplete, it will be returned so that you may have an opportunity to complete the information and resubmit it for consideration. Please allow at least two weeks for your application to be considered.

PATIENT INFORMATION

* Indicates required field

Last Name *

First Name *

Middle Initial *

Street Address *

City *

ZIP Code *

Home Phone *

Cellphone *

Email Address *

Date of Birth *

Social Security # *

Gender *

MEDICAL INFORMATION

To be completed by your physician: Current breast cancer Diagnosis & stage.

Reoccurrence? *

Yes No

Date of Diagnosis *

Breast(s) affected (one or both) *

DOCTOR INFORMATION (HIPAA Release) [45 C.F.R. § 164.508 (c)(ii) & Civ. Code § 56.11 (c)]

Medical Oncologist (Cancer Doctor) *

Direct Office Phone *

Medical Oncologist’s Signature *

Date of Signature *

Patient’s Signature (Authorizes Release of Medical Information) *

Patient's Date of Signature *

Description of each purpose for the use or release of the information: [45 C.F.R. § 164.508 (c)(iv)]
This information will be used for the sole purpose of evaluating the above patient for support services offered by The Jill Foundation. This HIPAA release is valid for a 180-day period from the patient’s signature date shown above and only if signed by both the patient and oncologist’s office.

WORK HISTORY

Salon Name *

Street Address *

City *

Salon Owner/Manager *

Phone *

Cosmotologist License Number *

Expiration Date *

How did you find out about The Jill Foundation?

Please add any comments or information you would like The Jill Foundation to know.

For administrative purposes, organizations involved with your case may be contacted to verify the information you have provided on this application. With your signature, you acknowledge and agree to the above stipulations.

Applicant’s Signature *

Applicant's Date of Signature *

Submit