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GALLAS STRONG FOUNDATION
APPLICATION
Our Mission:
To aid cancer-stricken families financially while they are going through their crisis; allowing them to focus their efforts on healing and fighting the cancer battle.
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Nominee Name
*
First and last name
Your answer
Nominator
*
First and last name
Your answer
Nominator Contact Number
*
Number we can reach you should we have any questions on the application
Your answer
Nominator relationship to nominee
*
Family
Friend
Co-worker
Other:
Nominee Resides in one of the following counties
*
Blanco
Comal
Kendall
Bexar (reside within the Comal school district)
Other:
Nominee Email
*
Your answer
Nominee Phone number
*
Your answer
Clinical Diagnosis
*
Your answer
Diagnosis Date
*
MM
/
DD
/
YYYY
Currently undergoing cancer treatment (i.e. chemo, immunotherapy, radiation, surgical tumor removal, etc.)
*
Choose
Yes
No
Name, age and relationship of those living in household
*
Your answer
Why are you nominating this family to receive a donation from the Gallas Strong Foundation?
*
Your answer
What will the donation be used for?
*
Your answer
Nominees employment status
*
Employed
Unemployed
Self Employed
Employed and sole provider for family
Retired
Other:
Send me a copy of my responses.
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