Child Sponsorship - Eligibility Questionnaire

Existing client?
   Have you been diagnosed with breast cancer?
    (If no, you do not qualify for this program.)
What was the date of your initial breast cancer diagnosis?
(Backed by medical documentation, provided later)
Are you in remission or active treatment?
If you are in remission or have "No evidence of disease", please provide that date.
Cancer Stage:
First Name
Last Name
Date of Birth
Phone
NOTE: Please use the same phone number, if filling out more than one form.
Email
Verify/Retype Email
Zipcode
City/State  
Household members (Adults 19 / Children 18 and below) Adults 19 :  Children: 
   Do you have medical documents stating these dates (diagnosis date / remission date)? This is required.
   Are you able to provide supporting documents (i.e. medical records, income verifcation, bills, etc) online as attachments with your application? This is Required.
   Can you complete and upload the HIPAA Compliant Authorization (filled out by you) and Medical Information Form (filled out by a medical professional).
   At the time of application (Not Now), Can you make the required $25.00 Pay-It-Forward-Contribution online? This contribution will assist others in need of UBCF services. (This is required.)
If the answer is no to any of the questions above, please indicate which question and provide a detailed explanation.
How did you hear about UBCF?