The Pink Connection | Apply for Assistance

Apply for Assistance
Board of Directors
Events

Apply for Assistance
Board of Directors
Events

Apply for Assistance

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The Pink Connection Emergency Relief Fund Application

"*" indicates required fields

APPLICANT INFORMATION

First Name*

Middle Initial*

Last Name*

Address*

Street Address Address Line 2 City State (MUST reside in Texas to apply) ZIP Code

Cell Phone Number*

Home Phone Number

Email Address*

Date of Birth*

Gender*

Female

Male

Gender Diverse

Prefer Not to Answer

Ethnicity*

Hispanic or Latino

Not Hispanic or Latino

Prefer Not to Answer

Preferred Language of Communication*

English

Spanish

BREAST CANCER INFORMATION

Date of breast cancer diagnosis*

(diagnosis MUST be within the past 18 months to apply)

Breast cancer type*

Ductal Carcinoma in Situ (DCIS)

Invasive Ductal Carcinoma

Invasive Lobular Carcinoma

Inflammatory Breast Cancer

Metaplastic Breast Cancer

Other (please specify below)

Please specify Breast Cancer type*

Breast cancer subtype*

TNBC (ER -/PR-/HER2-)

TPBC (ER+/PR+/HER2+)

ER-/HER2+

Unknown

Other (please specify below)

Please specify Breast Cancer subtype*

Current Stage*

Stage 0

Stage I

Stage II

Stage III

Stage IV

Undesignated

HEALTH INSURANCE INFORMATION

Please indicate type of insurance the applicant has. If applicant is uninsured select, ‘Uninsured’ (select all that apply)

Private Insurance

Medicaid

Medicare

Charity Care

VA Program

Medigap or Medicare Supplement

Unknown

Uninsured

How did you hear about The Pink Connection Emergency Relief Fund?*

Hospital/ Healthcare Provider (e.g. Doctor, Nurse, Navigator, Social Worker)

Internet/Radio/TV

The Pink Connection Website

Family/Friend/Another Individual with Breast Cancer

Social Media

Other (please specify below)

Please specify how you heard about us*

HOUSEHOLD FINANCIAL INFORMATION

Employment status*

Full Time

Part Time

Unemployed

Retired

Family Income sources (check all that apply)

Salary

Social Security

Pension

Retirement Savings

Short- or Long-Term Disability

Unemployment

Family or Friend Support

Other (please specify below)

Please specify other family income sources*

Number of People in household*

Current total annual household income*

FINANCIAL ASSISTANCE NEEDED

(Please select the most urgent care related financial need)*

Transportation

Rent or Housing

Utilities or Bills

Food or Groceries

Lymphedema Supplies or Care

Child Care

Elder Care

Home-Health Care

Hotel Stay

Side-effect Management Medication

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