Pink Bridge Gas and Grocery Assistance Application

GENERAL GUIDELINES AND CRITERIA TO RECEIVE FUNDING General Funding and Application Requirements: • Patient must be a US citizen and Georgia resident living in, or being treated in, the Central Georgia area. • Patient must have a breast cancer diagnosis and be in active treatment. Active treatment includes chemotherapy, radiation, surgery, reconstructive surgery, hospice or palliative care. • Patient meets the financial guidelines and criteria set by United in Pink. • Please understand we are not an emergency fund and cannot provide immediate assistance. • Meeting the guidelines and applying to the Pink Bridge Program does not guarantee funds will be available or offered. • Patient must submit: Statement of Need/Your Story Eligibility and Review Process: • United in Pink approves requests for limited gas and grocery card assistance. • Depending on the type of assistance requested, additional documentation may be required. • United in Pink selection committee will meet weekly to review submitted applications. Our review process may take 1-2 weeks. • Requests will ONLY be reviewed once all documents are received. Incomplete applications will not be reviewed. • The selection committee sets the eligibility criteria and has final determination in all cases. • Assistance is granted on a first-come, first-serve basis to the extent funding is available. • The Pink Bridge Program may only be able to assist a portion of the potential recipients who apply for aid. • If approved, payment will be made via Kroger and/or Walmart gift cards. • United in Pink reserves the right to refuse service to anyone. • Assistance will be terminated if any untrue or falsified information has been submitted.

First Name*

Last Name*

Today's Date*

Date of Breast Cancer Diagnosis*

Street Address*

City*

Zip Code*

Date of Birth*

Phone Number*

Email Address

How did you hear about United in Pink?*

Select or enter value

Have you spoken with the United in Pink Team?*

Select

Ethnicity

(for data collection purposes only)

Marital Status*

Select

Health Insurance*

(check all that apply)

Select or enter value

Current Treatment*

Select or enter value

Total number of people living in household?*

Type of support requested?*

Select or enter value

Amount Requested*

(amount may not exceed $150)

Statement of Need*

HOW HAS YOUR BREAST CANCER DIAGNOSIS AFFECTED YOUR FAMILY AND YOUR FINANCES?

Consent*

I verify that all information provided is accurate, that I am a US Citizen, I have been diagnosed with Breast Cancer, and I am being treated and/or live in Central Georgia. PLEASE TYPE NAME to verify.

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.