Cancer Survivors' Fund

Prosthetic Limb Assistance Application

 

PERSONAL DATA

First Name

MI

                   Last Name                             DOB
 

       
Permanent Street Address Line 1 Permanent Street Address Line 2
 
City State Zip

Age  

Phone e-mail
 

 

 

   

Describe yourself in one paragraph

            

Describe your family situation in one paragraph

            

    

 

Yes. I am willing to do volunteer work, share my experience with young patients with cancer or other medical challenges and provide them emotional support and guidance.

 

Have you previously performed volunteer work? If you did, please give details.

 

  

 

MEDICAL INFORMATION 

    Yes. I have been diagnosed with cancer.

Name of your Attending Physician

Name and Location of Hospital

   
Description of Need
 

 

SUPPLEMENTAL INFORMATION

Please mail the following documentation to:

Cancer Survivors' Fund

P.O. Box 792, Missouri City, TX 77459

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A letter from your attending physician verifying your medical history, current medical situation and description of the need for the prosthesis or artificial limb.

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A release from you, and your parents if you are a minor, that you agree to have your name and photo published in the news media as a recipient of Cancer Survivors' Fund medical assistance and that you agree to have your name, photo and your success story to be published on this website.

Download Release
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Please DO NOT print and mail this application or the essay. Use the Submit Application button below.

 

THE ESSAY 

 

Submit an essay with this application. Discuss the following question. HOW HAS MY EXPERIENCE WITH CANCER IMPACTED MY LIFE VALUES AND CAREER GOALS? Essays must be a minimum of 500 words and a maximum of 1200 words. Essays may be entered in the box below or submitted separately, attached to an e-mail. Please DO NOT mail.

 
       

Last Name
 

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