GiveBack

Application instructions: please complete entire form below

8Once we receive and review your application, you will receive a phone call to verify your information and eligibility. Approvals can take up to 2-3 weeks to process. The board members for the BarbaraCares Foundation meet on a monthly basis. Please be advised all applications will be reviewed at the next scheduled board meeting.

Instructions:
The BarbaraCares GiveBack in partnership with Cuisine For Healing will provide FREE healthy meals to breast cancer patients in Tarrant County. We understand the enormity of this journey and we count it a honor to help those in the fight by providing healthy nutritional food items while patients are in treatment. Please read carefully to complete the entire form. You may electronically submit the application, or print the application and scan it for consideration via email at: [email protected] or mail the completed application form to:

BarbaraCares
P.O. BOX 15007
FORT WORTH, TX 76119

BarbaraCares has implemented the following criteria which must be met to establish eligibility for assistance. If you answer Yes or meet the guidelines to all of the questions below, you qualify.

The criteria are as follows:

Must be a legal Texas resident (Please include valid driver’s license)
Must have a breast cancer diagnosis (Please send a copy of the diagnosis letter)
Be 18 years or older
Only one award allotment given per family/household within the specified period
Currently receiving cancer treatment including but not limited to: immunotherapy, radiation, surgery, chemotherapy, targeted therapy or clinical trials (Please send treatment schedule from physician).
Must include documentation supporting the diagnosis

In addition, the GiveBack program is only for those in active treatment residing in Tarrant County. This program is not in conjunction with any other grants/awards. Applicant must not have received assistance from The BarbaraCares Foundation in the past. Final approval for financial assistance is determined by the BarbaraCares Board of Directors.

BarbaraCares - Giveback Form

MENU SELECTIONS BELOW from cuisine for healing (PLEASE NOTE ITEMS ARE SUBJECT TO CHANGE). to see full food photos click the button:

Food Photos

* Indicates required field

Name *

First

Last

Select One. You Are Applying As: *

Breast Cancer Patient Care Giver N/A

Email *

Birthdate MM/DD/YYYY *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Copy your choices below in the box. Pick 7 entrée items (You may mix n match breakfast, sandwiches and soups items + 2 desert selections). Select Menu Choices from the website menu: https://cuisineforhealing.org/?v=7516fd43adaa *

Alternate Contact

Name *

First

Last

Phone Number *

Diagnosis of Patient *

Upload Diagnosis Letter *

Max file size: 20MB

Date of Diagnosis MM/DD?YYYY *

Is The Patient Currently In Treatment? *

Description and Frequency of Treatment *

Upload Treatment Schedule *

Max file size: 20MB

Referral *

Total Persons In Household? *

Total Annual Household Income? *

What is your current employment status? *

Employed Unemployed Self-Employed Student

Total Monthly Household Expenses *

Upload Driver's License *

Max file size: 20MB

Upload Supporting Documents For Consideration *

Max file size: 20MB

Additional Supporting Documents For Consideration *

Max file size: 20MB

Additional Supporting Documents For Consideration *

Max file size: 20MB

Have You Applied For Assistance Elsewhere? *

Where Have You Applied? *

Signature

Please read the following information carefully before signing and submitting: I hereby understand and recognize that the BarbaraCares Foundation GiveBack is part of the BarbaraCares Foundation, a Texas nonprofit corporation which is a recognized tax exempt organization pursuant to Internal Revenue Code Section 501 (c)(3). Each award and grant has been solely and exclusively established for the benefit of those persons diagnosed with breast cancer and to assist the caretakers providing support for breast cancer patients here in the state of Texas. Funds and resources provided are not based on marital status, race, gender, ethnicity, orientation or religion. However, funds are granted to provide assistance to those individuals who have a demonstrated financial need and live within the designated service area (the state of Texas).

Accordingly, I have read and affirm all the information provided is truthful and accurate. I hereby certify that the financial information disclosed on this application concerning my annual household income, expenses and insurance provider is true and accurate. I also certify to be true I am facing financial hardship. I further certify that I have been diagnosed with breast cancer or I am the caretaker of a patient currently receiving treatment as defined under the eligibility requirements.

I understand that if any of the information set forth above is false, the application will be denied and if funding has been released, the foundation will pursue any and all legal means available to retrieve disbursed funds.

By signing the signature/clicking the submit button below, I agree and give permission for the BarbaraCares Foundation to verify the provided information.

Submit

​barbaracares giveback

Application instructions: please complete entire form below

BarbaraCares - Giveback Form

MENU SELECTIONS BELOW from cuisine for healing (PLEASE NOTE ITEMS ARE SUBJECT TO CHANGE). to see full food photos click the button:

Alternate Contact

barbaracares giveback