Carefree Capping: Application for Funding
We, at Carefree Capping, want to be there for you during this very personal and difficult time. We offer needs-based funding for young adults undergoing chemotherapy in Michigan for Lymphoma (Hodgkin's and Non-Hodgkins) that wish to use cold cap therapy to reduce/ prevent hair loss. We have limited funding but will do our best to accommodate each of our applicants. Don't hesitate to reach out with any questions or to schedule a call with one of our team members. Email us to connect at carefreecapping@gmail.com, thank you!
Sign in to Google to save your progress. Learn more
What is your full name?  *
What is your date of birth?  *
MM
/
DD
/
YYYY
What is your preferred email address?  *
What is the gender you identify closest to?  *
What is your cancer diagnosis?  *
What is the total length of your treatment?  *
How often will you be receiving treatment? (1x month, 2x week, etc.) *
What date were you diagnosed?  *
MM
/
DD
/
YYYY
What treatment regime will you be receiving? Please let us know the drug type(s) and amounts, if possible.  *
What location will you be receiving treatment at?  *
What is your expected start date for chemotherapy, if known? 

Please note, we do NOT, in any circumstance, allocate funding after chemotherapy has started. 
What style of cold caps will you be using?  *
If you have health insurance, who is your provider? 
Have you spoken with your health insurance to ask if they cover cold capping? 
Clear selection
What is your occupation? 
What is your estimated monthly household gross income?  *
What are your estimated monthly household expenses?  *
What would receiving funding from Carefree Capping mean to you? Please tell us about your financial situation and why you are applying for a subsidy.  *
What subsidy amount would allow you to comfortably use cold cap therapy? *
Cold cap therapy requires a good support system, especially if you're using manual scalp cooling. Please tell us about your support system. If using a manual system, who will your capper be? Do they understand the time commitment that is required of them?  *
What is your phone number? A team member will be reaching out within 48 hours to chat with you about your application and the next steps.  *
What is your hematologist/ oncologists name and phone number?  *
There are some blood cancers within the Lymphoma family that are NOT permitted to use cold cap therapy during treatment. There are also some oncologists that do not support the use of cold cap therapy. By clicking "I agree", you are confirming that you have spoken to your doctor and been given explicit approval to use cold caps during your treatment.  *
You will be required to pay the security deposit in order to receive funding from us. By clicking "I agree", you are confirming that you understand this responsibility to put down the security deposit before Carefree Capping will send funds to the cold cap company of your selection. 
Clear selection
Please tell us any additional information that may be important when reviewing your application, or if you have any questions you'd like to discuss on the call. 

We're looking forward to talking with you! 
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms