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Financial Support Application
Name
Age
Gender
Male
Female
Date of Birth
Name of Parent/Guardian (If Minor)
Phone Number
Address
Address (cont.)
City
State
Country
Zip code
Email address
Dance Studio affiliation (if any)
What is your story and current diagnosis?
Have you received any financial assistance from any organization or charities? if so, please disclose the charity/organization which provided the assistance and the year the funds were given.
Have you done any charity work in the past? If so, please explain in detail.
In your own words please explain why you feel like you are a good candidate to receive financial support from DANCERS AGAINST CANCER.
Please submit medical documentation to verify the diagnosis of patient seeking financial assistance.
Please upload a photo of the potential recipient.
Please complete the
W-4 form
in its entirety and upload a scanned copy.
