Champions Can! Foundation for Cancer Wellness, Inc. Client Assistance Form
Please complete this form in its entirety.  Applicants must be a resident of the state of Georgia.

Information provided for the FINANCIAL and VOLUNTARY INFORMATION sections of this form will not be used in determining whether a grant/assistance will be provided by Champions Can! It is being collected to assist Champions Can! Foundation in demonstrating our community impact when seeking funding to support the foundation. Champions Can! does not discriminate on the basis of race, religion, age, nationality, gender or ethnicity. Information about a specific individual will not be shared.

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Email *
Full Name (Last, First) *
Age *
Date of Birth *
Gender *
Mailing Address *
County of Residence *
Best Contact Phone Number: *
Alternate Phone Number (Optional)
Primary Language *
If you answered "other" to language, please provide further details below:
If patient is currently unable to speak on the phone due to illness or hospitalization, or is not an English speaker, provide contact information for a friend or family member authorized by the patient to speak with us about this application. Please provide the name, phone number, and relationship to the patient.
Marital Status *
Number of People In Your Household *
Do you have cancer or are you a cancer survivor? *
What type of cancer were you diagnosed with? (Provide cancer staging if known) *
What was the date of your cancer diagnosis? *
What treatments have you had related to your cancer diagnosis? *
If you answered "other" to treatments related to your cancer diagnosis, please provide further details:
If you have not yet started treatment, please list when you are scheduled to have surgery or start chemotherapy and/or radiation
Are you still receiving treatment for your cancer? *
When did you have surgery? (Provide Date)
When did you complete chemotherapy? (Provide Date)
When did you complete radiation? (Provide Date)
Where did you receive treatment for your cancer? (Please list facilities and hospitals) *
Which physicians are providing your cancer care? (If applicable, include names and phone numbers of your Medical Oncologist, Surgical Oncologist, or Radiation Oncologist)
What type of assistance are you seeking from Champions Can Foundation for Cancer Wellness, Inc.? *
If you answered "other" for type of assistance you are seeking, please provide further details:
Have you previously received any type of assistance from Champions Can? *
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