Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Are you still receiving a salary from the employer listed above?

Yes

No

Is anyone in your immediate family helping you financially?

Yes

No

Has anyone held a fundraiser for you?

Yes

No

Birthdate *

MM

DD

YYYY

Date of diagnosis *

MM

DD

YYYY

Publicity Release

I agree to have myy story and photograph in the media which will include our website, social media as well as local and national media.

Please do not use my photo or story, I understand this may limit the resources available to help me financially.

Have you or are you receiving financial assistance from another source?

Yes

No

Date of signature *

MM

DD

YYYY

Terms and Conditions *

I AGREE to all of Shirley's Way terms and conditions.

HIPPA Form *

I authorize Shirley's Way and all their representatives along with my physician to receive medical information. (Please fill out, sign and return HIPPA Form found above to info@shirleysway.com)

Agreement *

I AGREE that everything on this application is completely true to the extent of my knowledge.