Wish Fund - Eligibility Questionnaire
Existing client?
Have you been diagnosed with stage IV breast cancer?
(If no, you do not qualify for this program.)
What was the date of your Stage IV breast cancer diagnosis?
(Backed by medical documentation, provided later)
Cancer Stage:
Stage 0
Stage 01
Stage 02
Stage 03
Stage 04
Undesignated
First Name
Last Name
Date of Birth
Phone
NOTE: Please use the same phone number, if filling out more than one form.
Email
Verify/Retype Email
Zipcode
City/State
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
DC
AE
AA
AP
Household members (Adults 19 / Children 18 and below)
Adults 19 :
1
2
3
4
5
6
7
8
9
10
Children:
0
1
2
3
4
5
6
7
8
9
10
Do you have medical documents stating these dates (diagnosis date / remission date)? This is required.
Are you able to provide supporting documents (i.e. medical records, income verifcation, bills, etc) online as attachments with your application? This is Required.
Can you complete and upload the
HIPAA Compliant Authorization
(filled out by you) and Medical Information Form (filled out by a medical professional).
How did you hear about UBCF?
