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Winter storm help

"The hope I have is to provide hope to others so that they will in turn give hope to others and press on in life.” -Barbara Sanders-Holland

BarbaraCares - Winter storm assistance form

The BarbaraCares Foundation is aware of the significant impact this winter storm has caused for many across the state of Texas. In response to the unprecedented toil this storm has had on residents across the state, the Board of Directors has agreed to provide one-time gift cards to past grant recipients through the Foundation. A limited number of additional breast cancer patients (in active treatment) will also be eligible for a one-time gift card (while supplies last). We are humbled to assist those in need. Gift cards will be sent electronically or mailed.

Instructions:
Please read carefully to complete the entire form. You may electronically submit this request, or print the request and scan it for consideration via email at: [email protected] or mail the completed 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)
Only one gift card given per family/household
Must have a valid email address (Gift cards will be emailed directly OR mailed as an alternate means)
Must be a prior award recipient through BarbaraCares OR a breast cancer patient undergoing active treatment
Treatments are defined but not limited to: immunotherapy, radiation, surgery, chemotherapy, targeted therapy, or clinical trials. (Please send treatment schedule from physician).
Be 18 years or older
If you are a new applicant, must include documentation supporting the diagnosis

* Indicates required field

Name *

First

Last

Email *

Birthdate MM/DD/YYYY *

Phone Number *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Upload Driver's License *

Max file size: 20MB

Total Persons In Household? *

Total Annual Household Income? *

Have You Received Assistance From BarbaraCares Before? *

Yes No

Where You Affected By The Recent Winter Storm? (Feb 13 - 19, 2021) *

Yes No

Explain How You Were Affected? *

Please list all expenses you are requesting for including: travel, meals, utilities, counseling, etc. Must include a copy of most recent bill(s). Upload below or send to: [email protected]

What is your current employment status? *

Employed Unemployed Self-Employed Student

Type of Assistance You Are Requesting? *

Walmart Gift Card

Have You Been Affected By COVID-19 *

Yes No

If "Yes" Please Explain *

COMPLETE THIS SECTION IF YOU ARE A NEW APPLICANT THROUGH BARBARACARES

Only complete this section if you are a first-time applicant. If you have already received funding from BarbaraCares,
you do not need to fill this section.

Are You A New Applicant? *

Yes, I have not received assistance through BarbaraCares before No, I have received assistance before from BarbaraCares

Are You A Breast Cancer Patient? *

Yes No

Current Diagnosis *

Please upload below or send a copy of diagnosis letter to: [email protected]

Upload Diagnosis Letter *

Max file size: 20MB

Date of Diagnosis MM/DD?YYYY *

Are You Currently In Treatment? *

Description and Frequency of Treatment *

Please upload below or send a copy of the treatment schedule to: [email protected]

Upload Treatment Schedule *

Max file size: 20MB

Were You Referred? *

Name (Representative) and Agency of Referral *

Signature
Please read the following information carefully before signing and submitting: I hereby understand and recognize that the BarbaraCares Foundation Winter Storm Assistance Application 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). Funding 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 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

Share Your story

The BarbaraCares Foundation counts it a tremendous honor to serve the community. Every applicant, every email, every call and referral we are humbled for the opportunity to do what we can to lighten the load for both patients and caregivers.
If we have ever been instrumental in any form or fashion, we would love to hear your story!

This organization was started with the sole purpose in mind to give back. Hearing from you, further reminds us that we are doing our part to inspire, educate, support and transform lives. Our fight against breast cancer starts with each individual we assist.
Share your story with us and any difference we've made in your life.

LEAVE A TESTIMONIAL

CLICK TO GIVE HERE

​​Winter storm help

​BarbaraCares - Winter storm assistance form

COMPLETE THIS SECTION IF YOU ARE A NEW APPLICANT THROUGH BARBARACARES

Share Your story

Winter storm help

BarbaraCares - Winter storm assistance form