Apply for Support

Applicant Information
Full Name*

First NameMiddle NameLast Name
Age*
E-mail*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone*

Area CodePhone Number
Alternate Phone

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

YesNo
Full Name

First NameLast 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*

MonthDayYear
Please mark your type of sarcoma.*

OsteosarcomaLiposarcomaLeiomyosarcomaChondrosarcomaMFHSynovial sarcomaEwing’s sarcomaEpithelioid sarcomaMPNSTFibrosarcomaAngiosarcomaRhabdomyosarcomaAdamantinomaHemangiopericytomaUndifferentiated sarcomaOther
Hospital or Institution of Treatment*

GHSMUSCMD AndersonDukeEmoryCharlotte/ CMCOther
Treatment(s)*

ChemotherapyRadiationSurgerySurgery with amputationOther
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*

Upload a File

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Second file

Upload a File

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Details of Request
Amount Requested*
Date needed*

MonthDayYear
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.*

Upload a File

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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*

MonthDayYear
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*

MonthDayYear
Initials to Indicate Agreement*
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