Valley Girls & Guys!/Mountain for Mammaries Grant Application

Valley Girls & Guys!/Mountain for Mammaries Grant ApplicationJeffsne2022-05-17T14:18:00-07:00

Mountain for Mammaries is a grassroots organization founded by a local area breast cancer survivor, who firmly believes it was the life saving gift of early detection that gave her options in her fight against breast cancer.

She vowed that she would do what she could to stand in the gap and help others gain access to this life saving gift. Since 2013, M4M has raised over $84,041.00 to assist those in need of diagnostic services.

For your application to be considered, you must be:

uninsured, under-insured or facing out of pocket expenses that exceed your ability to pay, thereby creating a financial hardship (ex. high deductible). M4M must verify financial need for your application to be considered for eligibility. Applicant acknowledges this will include the release of protected health information between M4M and Valley Medical Center.

We are unable to assist with treatment costs; grant funds are for diagnostic procedures only.

Name*
First Middle Last
Date of Birth*
MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State ZIP Code
Email*
Please give us an email where we can reach you.
Phone*
Gender*
- Female
- Male
Marital Status*
- Single
- Married
- Divorced
- Widow/Widower
Do you have children?*
- Yes
- No
If yes, number & age of child(ren)
Known family history of breast cancer*
- Yes
- No
- Unknown
If yes, relationship to patient
Their age at time of diagnosis
Do you have any of the following:
- Pain
- Discharge
- Palpable Lump
Name of primary care physician
Are you currently employed?*
- Yes
- No
Do you have insurance?*
- Yes
- No
If yes, what is your deductible*
How will these fund help?*
Briefly explain your current situation and how these funds would help you:
Willing to share your story?*
If you are selected to receive M4M funding, would you be willing to share your story?
- Yes
- No
Acknowledgement*
- To be considered for financial assistance and diagnostic services, applicant agrees to hold M4M, Valley Girls & Guys, and their collective board members, harmless from any and all injuries, damages, losses, claims, potential delays or misdiagnosis that may result due to acts or omissions of the service provider.
Name
This field is for validation purposes and should be left unchanged.

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