Stomp Out Breast Cancer Foundation Confidential Grant Application
Mission:  The Stomp Out Breast Cancer Foundation is ~ empowered with knowledge, strengthened through action, sustained by community ~ dedicated to working with African American women to promote breast health and support women living through the transformative diagnosis of breast cancer.  
 
Purpose:  Provide education, screening, financial assistance and support to persons impacted at little to no cost, to change the prognosis for this community.

Client base:  People of Color; Target Group:  African American women/men

Goal:  Reduce the breast cancer prognosis/diagnosis of African American women in Colorado by at least 25%

If you are in active treatment for breast cancer and live in Colorado, please fill out the google form below.

Email *
Stomp Out Breast Cancer Foundation Inc.
Type of Grant (check all that apply) *
Required
Do you have medical insurance? *
Required
If yes, who are you insured with?
Are you in active treatment? (*Active treatment is defined as the period after positive diagnosis of breast cancer has been made, you have received a treatment plan from your doctor and will be receiving chemotherapy, radiation or a surgical procedure. A surgical procedure is defined as a single or bi-lateral mastectomy, lumpectomy, axillary dissection or sentinel node biopsy. Reconstruction does not qualify as Active Treatment.) *
Reason for applying *
Grant funds made payable to (name of company, account number and amount) *
Applicants Name *
Applicants Full Address including city, and zip (Colorado residents only) *
Applicants Phone Number *
Applicants date of diagnosis/prognosis *
MM
/
DD
/
YYYY
Age Range *
Gender *
Ethnicity *
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms