top of page

Program Application 
Requirements

Do you qualify for our program? If you fall into the requirements below, you might!
Requirements:

 

  1. You must be in active treatment for breast cancer by receiving one or more of the following: chemotherapy, radiation, upcoming surgery ( lumpectomy/mastectomy ).​

  2. You must be a resident of or be receiving treatment in Larimer or Weld County.

  3. You must be 18+ years of age.

If you fall into these categories, fill out the form to the right, or DOWNLOAD OUR APPLICATION here.
 

Once completed, signed/dated, print and mail to: 
Hope Lives!
Att:  Elise Carver 
2627 Redwing Rd, Suite 210 Fort Collins, 80526
or email the application to info@hopelives.org

APPLICATION FOR BREAST CANCER SERVICE ASSISTANCE

Dear Applicant: Hope Lives! was created to assist individuals undergoing breast cancer treatment by alleviating the physical, emotional, and financial side effects of treatment.  
APPLICANT’S FULL NAME:
MAILING ADDRESS:
EMERGENCY CONTACT:
*Hope Lives! reserves the right to communicate with this individual after a phone or email attempt to contact you has been unsuccessful.
VERIFICATION OF TREATMENT
Regarding my care and treatment, I, hereby verify that I am in the care of my physician and that under his/her supervision I am receiving treatment for breast cancer in the form of: 
TREATMENT
PLEASE NOTE:
- Mammosite Radiation, or Hormonal Therapy are      not qualifying therapies.

- Reconstruction is not covered by our program.
WHAT SERVICES ARE YOU INTERESTED IN?
Mark all that apply
DIAGNOSIS STATUS I understand that it may be necessary to verify my medical status. 
Is this your first Breast Cancer diagnosis?
DEMOGRAPHIC PROFILE
Gender Identity
Are you Hispanic, Latino, or Spanish origin?
Marital Status
Do you have children or grandchildren?
Do you have others living with you?
Do you have someone to help you during recovery?
Are you employed?
*( For reporting purposes only - Hope Lives! provides services to qualified applicants regardless of income or employment status )

Thanks for submitting!

bottom of page