Apply for Support

Applicant Information
Full Name *

First Name Middle Name Last Name
Age *
E-mail *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone

Area Code Phone Number
Cell Phone *

Area Code Phone Number
Alternate Phone

Area Code Phone Number
Is the person completing this application the actual applicant? *

Yes No
Full Name

First Name Last Name
E-mail
Relationship to Applicant
Featured Warrior

I want to be a Featured Warrior. I am applying for general support.
Medical Information
Date of Diagnosis *

Month Day Year
Please mark your type of sarcoma. *

Osteosarcoma Liposarcoma Leiomyosarcoma Chondrosarcoma MFH Synovial sarcoma Ewing’s sarcoma Epithelioid sarcoma MPNST Fibrosarcoma Angiosarcoma Rhabdomyosarcoma Adamantinoma Hemangiopericytoma Undifferentiated sarcoma
Hospital or Institution of Treatment *

GHS MUSC MD Anderson Duke Emory Charlotte/ CMC
Treatment(s) *

Chemotherapy Radiation Surgery Surgery with amputation
Please upload one or more of the following: a. An official statement or letter of support from the applicant’s treating physician B. An official statement from the applicant’s hospital of record C. An official operative or pathology report that describes the sarcoma *
Second file
Details of Request
Amount Requested *
Date needed *

Month Day Year
Please describe your need in your own words (400 word limit). *
Please upload official documentation from the entity to whom the expense is owed showing the money owed and showing that the applicant is responsible for the bill. *
Additional Questions for Featured Warrior Applicants
Tell us a little about your family. *
Tell us about being diagnosed. *
How has having sarcoma changed your life? / How has it changed your perspective on life? *
What has been the greatest challenge you’ve faced in your battle against sarcoma? *
Where are you now in your treatment? *
What will these funds mean for you and your family? *
DISCLAIMERS AND CERTIFICATIONS *

I understand that this application, once submitted, becomes property of Sarcoma Warriors of the Upstate. Submission of an application is considered to be an act of acceptance of the eligibility requirements. All of the information contained within this application will be kept confidential and be made available only to those Board Members involved in rendering award decisions. I hereby understand that the information provided in this application, including the supplemental materials, is complete and correct to the best of my knowledge and I submit my application without reservation.
Today's Date *

Month Day Year
Initials to Indicate Agreement *
FUTURE USE AND PUBLICATION CLAUSE

FUTURE USE AND PUBLICATION CLAUSE Award recipients will be asked to allow Sarcoma Warriors of the Upstate to use their name, their award, and the purpose of their award in future electronic or print publications for the purpose of promoting the organization and its cause in an effort to reach an increasingly larger audience. Your willingness to participate will not affect the decision by the board to grant an award. Agreement with the use of your name, award, and award history in this manner is conferred by click and initialling here.
Today's Date *

Month Day Year
Initials to Indicate Agreement *
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