Empower 2 Stay
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Eligibility & Services
Eligibility To be eligible for our services, an individual must be a resident of Northern Indiana and the surrounding cities, and be receiving or about to receive cancer treatment as defined below: • Chemotherapy • Mastectomy (Post-Operative) • Extensive Surgical Procedure • Biologic Therapy for Metastatic Breast Cancer Exclusions for eligibility: Oral therapy (e.g. Tamoxifen) or lumpectomy as single treatment. If you, or someone you know, believe that you are eligible for our services, please let us know. Please contact us to request for an application form.
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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 Subject to change based on economic conditions and individual circumstances. 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
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Privacy Policy
Consumer Privacy at Empower2stay Foundation E2S Foundation respects the privacy of our website users and purchasers and understands the importance of the information entrusted to us. Listed below are the policies and procedures E2S Foundation have in place with respect to your information. Information E2S Foundation May Collect information that can identify you (personal information). Personal information may include, but not be limited to, name, address, phone number, email address, and other related information. This information may be collected when you or other users provided to us while using our website or when submitting applications orders via phone, fax, or mail. Personal information may also be collected from third parties. We also may choose to combine information from multiple sources. We may also collect other types of information when you visit : www.empower2stay.com *Our server logs automatically collect information, such as IP address, browser type and language, and the date and time of site visits; helping us track users’ movements around our site and understand trends. *Our site may assign your computer cookies allowing us to collect information to facilitate access to our website and to personalize your online experience. *We may use standard internet tools, such as web beacons, that track use of our website thereby enabling us to customize our services. *E2S Foundation does not knowingly collect personal information from children under the age of 13. In the event this occurs, E2S Foundation will comply with the Children’s Online Privacy Protection Act. Information Others May Collect In certain instances, E2S Foundation may allow third party vendors to display advertisements on www.empower2stay.com website. Personal information of our users will not be shared with these companies; only general demographic statistics. If you post information about yourself or others, or communicate with others using our website, please note that we cannot control who reads your postings or what they may do with the information you provide. We encourage you to use caution when posting personal information on this site or any other. Ways E2S Foundation May Use Information Collected *To fulfill your order *To offer products and services that may be of interest to you *To customize the advertising and content on www.empower2stay.com *To facilitate use of our website *To manage your account and your preferences *To analyze website use thereby allowing us to improve our site as well as the products we offer *To identify and protect against fraudulent transactions and other misuses of our website *To enforce our terms of use With Whom E2S Foundation May Share Collected Information Personal information will not be shared with others except as indicated below, or except when we inform you in advance and give you the opportunity to opt out. *Service providers, such as credit card payment processors, performing services on our behalf *Other third parties in limited circumstances such as complying with legal requirements, preventing fraud, and protecting the safety of our users. We may share aggregated, non-personal information in any of the above situations as well as other, non-identified situations, to help us as well as third parties better understand our market. As a User, You May Choose: *Not to provider personal information, although that may result in your inability to obtain certain products, services, or use certain features on our website. *To stop receiving promotional emails or electronic newsletters from us by sending an email to the contact address at the bottom of this policy or by “unsubscribing” at the bottom of our newsletter. *To delete or decline cookies by changing your browser settings, although if you do this, some of our website features may not function properly. *To review and update your personal information by contacting us at the email address below or via the mailing address below. Websites We Link To www.empower2stay.com contains links to other third party websites. Be aware that these websites may collect information from you. E2S Foundation is not aware of or responsible for knowing the privacy policies of these sites and is therefore not responsible for any resulting issues. We encourage you to be aware when you leave www.empower2stay.com of the new site and the privacy policies of that site.
Donor Bill Of Rights
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Donation Amount* ☐$25 ☐$50 ☐$100 ☐$250 ☐$500 ☐$1,000 ☐$2,000 ☐$2,500 ☐$3,000 ☐$4,000 ☐$5,000 ☐Other $Click or tap here to enter text. Donation Frequency Choose an item. Company Click or tap here to enter text. Title Click or tap here to enter text. First Name Click or tap here to enter text. Last Name Click or tap here to enter text. Country* Choose an item. Address Lines* Click or tap here to enter text. ☐Yes ☐No ☐If this is a business and you want additional information to be added besides your name, please email it to us at services@empower2stay.com
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