TJ & Friends Foundation, Inc.
Ride to Live, LIve to Ride, Live Strong
Submit this completed application along with the required documentation to PO Box 6161, Elberton, GA 30635.
_______________________________________________________________________________________________________
Name _________________________________________________________________
Physical address:
_______________________________________________________________________
Street
City
State
Zip
_______________________________________________________________________
Contact numbers:
________________________________________________________________________
Home phone
Cell phone
Email address:
_______________________________________________________________________________________________________
Cancer diagnosis:
Type of cancer:
Date of Diagnosis:
_______________________________________________________________________________________________________
Statement of need: Describe your need
for this monetary donation.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________________________
Statement of
involvement in your community:
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________________________
Please
attach the following documents with your application. Failure to submit these
items will classify your application
NOT COMPLETE, therefore will not be reviewed until the required documents are
submitted.
Proof
of cancer diagnosis:
_______ (initial) You must attach a signed and notarized statement from your attending physician, currently treating you for cancer, confirming cancer diagnosis.
DO NOT SEND PATHOLOGY
REPORTS OR OTHER MEDICAL DOCUMENTS!!
Proof
of residency:
_______
(initial) You must attach a copy of local tax documents, a
signed and notarized statement from your landlord, or a voter's
registration card proving you
have been a resident of one of the following
counties for at least one year prior to your diagnosis; Elbert, Hart, Franklin,
Madison, Lincoln, Oglethorpe, or Wilkes County.
DO NOT SEND STATE OR
FEDERAL TAX DOCUMENTS.
Poof of citizenship to the United States:
_______
(initial) You must attach a copy of your birth certificate or passport
in order to prove that you are a citizen of the United States.
Medical
Information Release:
_______ (initial) I authorize the release of my
medical information to the TJ & Friends Cancer Foundation for the purpose
of verifying my cancer diagnosis in order to complete my application.
By
signing below I promise that all information contained in and attached to this
application is true. I authorize and release this information for the sole use
of
TJ& Friends Foundation, Inc. in order to receive the donation.
If
applicant is under age 18 or elderly, a family member or guardian signs as witness.
_______________________________________________
Signature
of applicant
_______________________________________________
Witness
Do
not write below this line
________________________________________________________________________________________________________
Date
received completed application__________________________________
Date
reviewed by board of directors___________________________________
Accepted______________________
Declined______________________
Date
of donation______________________________ check #____________________