This application is ONLY for women with breast cancer living on Staten Island who are in need of financial assistance due to dire necessity and need assistance to cover co-payment for cancer medication regardless of stage or phase of breast cancer. Assistance provided as funding is available; $30 – $50 per request. Your personal information will not be shared with others. Women will be asked to self-identify, and/or if not already connected with Cancer Tamer, will be asked to provide a letter from their hospital social worker that confirms breast cancer diagnosis. Membership with Cancer Tamer is not required. Assistance will be made through PayPal. If you do not have a PayPal account, we will work with you to provide the assistance. No one is entitled to this financial assistance! Cancer Tamer Foundation is merely trying to assist other women with breast cancer during this crisis as we know what it’s like to need help. Individuals will be selected on a first come basis. Preference will be given to single mothers, those with single incomes, seniors, and those with highest level of need. Assistance provided as donations are received from other community members and other supporters of Cancer Tamer.

Name: _____________________________________________________________________

Address: ___________________________________________________________________

Phone: _________________ email: ______________________________________________

Date of diagnosis: _____________________Diagnosis: ______________________________

Stage: ________________  Age ___________

Single income household: (Yes/No) ______________ Children: _________________________

If you are currently undergoing treatment, please advise what is being done.

Please share a little information as to why you are applying for this assistance.   ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Please understand that application does not guarantee assistance will be available. Preference will be given to women with the highest need regardless of age, nationality, ethnicity, stage or phase of diagnosis. Only $30 – $50 will be provided to each woman. Your donation to assist other women would be greatly appreciated but not required. Donation can be made at: PayPal.me/CancerTamer

Questions, please contact us. Stay safe and healthy.

Live with ROARING passion,

Dr. Charley Ferrer, CEO & President, Cancer Tamer Foundation

Download this application and email it to us at: info@cancerTamer.org