GLYNIS CANCER FOUNDATION
OPERATION OUTREACH & EMPOWER
Holiday Blessing Outreach Application Form
Dear Applicant,
Thank you for reaching out to us regarding our Annual Holiday Blessing as part of our Operation Outreach & Empower Program!
We understand that dealing with cancer can be very challenging for the entire family – physically, emotionally, and financially. That’s why as part of our Christmas celebration, we are committed to making the holidays better for other families too.
We review all applications and select five (5) families to assist during the Christmas holiday season. However, if your name is not selected, you may be selected to receive assistance after the holiday season.
In order to apply, you must adhere to the following guidelines. Because of the number of families in need, the following information MUST BE PROVIDED and no exceptions will be made.
Program Guidelines
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The patient must be on active treatment or within one year of treatment in order for the family to qualify
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All children must be within the age of 0-12 years old and the maximum number of children within the household cannot exceed five (5)
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Applicants must reside in the Memphis metropolitan area
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Applicants must submit a completed application no later than Monday, December 9, 2019. Applications submitted after this date will not be considered for assistance for the 2019 Christmas holiday
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Applicants must submit a current utility bill in the applicant’s name (not the landlord) as proof of address/residence (attach below)
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Selected applicants must appear in person to receive all food and gifts during the Breast Cancer Awareness Roundtable Empowerment Discussion on Saturday, December 21, 2019 from 1pm-3pm Central Standard Time. This event is open to the entire family and focuses on the educational, financial, and emotional impact that cancer has on the family. Selected candidates MUST ARRIVE ON TIME for this event. All food and gifts will be distributed during this event.
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Selected applicants must present a valid, State-issued photo ID at the event. No exceptions will be made if we are unable to verify identity.
How did you hear about the Glynis Cancer Foundation?
Have you or anyone in your household applied for or requested Christmas assistance at any other location or agency this year?
If yes, what agency?
Have you or anyone else in your household been recently diagnosed with cancer, being treated for cancer, or in post treatment for cancer?
If yes, who and what type of cancer?
Date of Diagnosis:
PATIENT INFORMATION
First Name:
Last Name:
Date of Birth:
Age:
Sex:
Address:
Home Phone:
Mobile Phone:
Email Address:
PATIENT AND SPOUSE/SIGNIFICANT OTHER INFORMATION
DEPENDENT CHILDREN INFORMATION
DIETARY PREFERENCE (SELECT BEST OPTION)
Note any special dietary needs or restrictions:
Please attach current utility bill by clicking the upload button:
All required fields must be filled in to submit the form.
Please email support at glynisyay@gmail.com if you have any issues submitting this form.