Application For Assistance

EMPOWER 2 STAY FOUNDATION, CORP.

Dear Applicant:
The Empower 2 Stay Foundation was created to assist individuals and their families undergoing cancer treatment, by providing individualized services. Awards are offered in an amount not to exceed the allocation for service of choice. Allocations are listed below.
$400 – 1,000 for groceries – $75 for every week of treatment. (This is given only during treatment week)
$400 – $4,000 for hair loss prevention – (1 up to 12 treatments) Funds are sent to the company providing the service.
$50 – Childcare
$ 25 – gasoline gift card per treatment week.
*. These funds are used to pay for personal services, selected by each recipient. Empower 2 Stay services are listed below. To qualify for assistance, applicants must be undergoing Cancer treatment by currently receiving one or more of the following treatments: chemotherapy, radiation, or cancer related surgery.
To apply, please complete and sign the following pages. Page two must be completed by your treatment physician (surgeon or oncologist). Submit the application as soon as possible; patient must be in active treatment to qualify.
Mail your application to:
Empower2stay – 12262 Leo Road Fort Wayne, IN 46845
Or for faster response, email the completed form to us at admin@empower2stay.com
We look forward to serving you. Feel free to call with any questions at (260-415-7657).

Applicant’s Full Name: First: ______________________M.I._______________ Last: _________________________________________ Address: ________________________________________________________ City, State, Zip: _ Phone: ( ) E-mail Address: ________________________
County of Residence: _________Date of Birth: __________ Age _ Alternative Contact (Optional) Name: ______________ Phone Number: _____

Please select the service(s) that would be most beneficial to you: (You can pick up to 2 services)
_ Hair Loss Prevention / Cooling Cap. Please consult your physician if treatment is suitable for you. Childcare
Groceries Gift Cards _ Transportation Support (gasoline gift cards). If Empower2stay vehicle is not available

Physician’s Verification of Patient/Applicant’s Treatment

Regarding the care and treatment of ________________, I__________________________________, hereby verify that I am her physician and that under my supervision she is receiving treatment for ______ cancer in the form of:
Treatment:
Mastectomy Date: _
Chemotherapy Date: _
Start Date (mm/ yy ) End Date (mm/ yy)
Chemotherapy – Number of treatments _ _ ____
Radiation _ _ Please list current medications related to cancer treatment: _____________ _________________________________________________________________
Diagnosis Status:
Initial diagnosis – Date: Recurrence – Date: _ Metastasis – Date: _
Physician’s Signature: ___________ Printed Name: __________________
Printed Address: _______________ City, State, Zip: _________________
Specialty: ________
Social Worker/Navigator/RN: ______ Phone Number: () _______________ Health Care System or Group: _____
Consent for Empower2stay to Contact my Supervising Physician.
I________________________, the undersigned and above referenced and identified Applicant, hereby consent the Empower2Stay Foundation Corp. (“E2S”) contacting my supervising physician, identified above, to verify that I have __________________cancer, my treatment and my restrictions relative to receiving services from E2S. I request that my physician complete this form, verify the information requested above, clarify if needed by Empower2Sstay, and return this form to me for final signature. This consent expires thirty (30) days after the date below.

Date_________________ Applicant’s Signature ________________________ EMPOWER2STAY. 12262 Leo Road, Fort Wayne, IN, 46845. admin@Empower2stay.com

Subject to change based on economic conditions and individual circumstances.