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PATIENT’S INFORMATION

First Name*

Middle Name

Last Name*

Home Address

Street*

City*

State*

Zip*

Home Phone*

Best Time To Call*

Work Phone*

Date of Birth(MM/DD/YY)*

Last four digits of patient's social security number (for adult applications only)*

E-mail*

Referred By*

MEDICAL INFORMATION

Please Upload a Copy of your Pathology / MRI Report for Verification purposes. Please NOTE: A letter from a doctor's office is NOT acceptable. An image/scan of a brain tumor or head scar is NOT acceptable. A hospital report clearly showing the patient's name and the name of the hospital and the diagnosis of a brain tumor is required.**

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Physician's Name*

Facility*

Phone*

Nurse/Social Worker*

Facility*

Phone*

PERSONAL AND FAMILY INFORMATION

Marital Status*

How many persons are living in your household? (Include yourself, all adults and children)*

Are you currently employed?*

Do you have health insurance*

Level of deductible

Type*

Total after tax household income per year (including all persons living in household)*

Net Worth

Mission4Maureen is a tax-exempt, non-profit foundation. As such, Mission4Maureen may engage only in those activities, which are charitable in nature. Mission4Maureen may provide grants to individuals to “provide financial relief ” or to aid individuals in “distress.” The information, which you provide, on this Net Worth Statement will be used exclusively by the foundation to determine your eligibility for financial assistance. The foundation will not disseminate or release the provided information to outside sources without first obtaining your prior express consent. The following financial information is being submitted by the applicant in consideration of possible financial assistance.

I. Assets

A. Liquid Assets Current Value in ($)

Cash on Hand*

Checking Account*

Savings Account*

Other Liquid Assets*

Total*

B. Fixed Assets Current Value in ($)

Value of Principal Residence*

Equity in Principal Residence*

Automobile(s) Personal Property*

Other Fixed Assets*

Net Total*

II. Liabilities: Total Current Balance in ($)

Student Loans*

Monthly Mortgage Payment (Principal residence) OR*

Rent paid*

Personal Lines of Credit*

Auto Loan/ Lease payments*

Home Equity Loan*

Real Estate Taxes Due*

Income Taxes Due*

Credit Card Debt*

Other Liabilities & Expenses*

TOTAL*

Liabilities: Monthly Payment in ($)

Student Loans*

Monthly Mortgage Payment (Principal residence) OR*

Rent paid*

Personal Lines of Credit*

Auto Loan/ Lease payments*

Home Equity Loan*

Real Estate Taxes Due*

Income Taxes Due*

Credit Card Payments*

Monthly Utility Payments (phone, heat, electricity, water, internet etc.)*

Other Liabilities & Expenses*

TOTAL*

Medical Release

Please read and e-sign below. Make sure to have this medical release e-signed and dated by a witness (an adult 18 or older other than yourself).

I understand and grant my permission to all my doctors, social workers, clinics and hospitals to release all healthcare and billing information relating to my treatment and care for brain cancer and other related health problems to the Mission4Maureen Foundation. I also grant my permission to discuss the above information with any designated representative of Mission4Maureen by phone.

Mission4Maureen agrees that all medical information will remain confidential and any reports written about the program will not use any participants’ names without their express permission. I specifically authorize the release of all my healthcare and billing information in your organization’s possession. The purpose of my request is to assist Mission4 Maureen in determining my eligibility for financial assistance. This Release and Authorization shall expire twelve (12) months from its execution if not revoked prior thereto. Mission4Maureen will not disseminate or release these medical records to any outside source without first obtaining prior express consent. I understand and agree that fulfillment of assistance may result in publicity whether or not Mission4Maureen actively takes steps to publicize its service. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by the Mission4 Maureen foundation. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered. I understand and agree that no promises or assurances whatsoever have been made to me by any representatives of Mission4Maureen regarding the assistance I am requesting.

PUBLICITY NOTICE-RELEASE

Mission4Maureen may hold events and fundraisers throughout the year to raise money to fund the primary objective of the foundation: to help families endure the staggering cost of brain cancer treatment. People continue to support us because they want to see their money find its way to the people who need it the most. We need your help to put a face and a name to that reality. To this end we will use your photo, your name, and your submitted story. If your application is approved, Mission4Maureen may also use a brief description of how the assistance that you received has helped you. This will facilitate communication with our donors and help in attracting more contributors. Please acknowledge this notice-release by e-signing below:I hereby acknowledge that Mission4Maureen may use my name, photo, background and story in PR and marketing materials which will include, but not be limited to, its newsletters, website, mailings and general information brochures.

Patient's Name*

Date of Birth*

Address*

Patient's E-Signature*

Today's Date*

E-sign*

Witness(an adult 18 or older other than yourself)*

Witness E-Signature*

Witness date*

Spouse, Parent or Guardian (if patient is unable to complete)

Service or Payment Requested: (type of bills for which you are requesting payment; i.e., utilities, doctor, rent, etc...)*

Amount Requested: (total dollar amount you are requesting, minimum: $100)*

Photo - a digital photo of yourself or your family**

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Story: ( The board has no way of knowing you except through this application. Therefore, we would like you to tell us about your brain tumor journey and about yourself, your family and your most immediate urgent needs so that we might better understand your need for our assistance. Please write your story in the space provided.*

Please note: If approved, you will be contacted through the email address that you have provided in this application. Applications submitted WITHOUT the required elements WILL NOT BE CONSIDERED.

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