Living Waters Financial Assistance Program Application
To review your request for financial assistance, please complete this application and attach the following documents if you are actively undergoing treatment. Active treatment such as surgery, chemotherapy, or radiation therapy for breast cancer.
The following documents must be uploaded and attached with this application:
Current letter/statement of cancer diagnosis from physician to include full name, date of birth, and present treatment plan.
A valid copy of your current Florida Picture ID or Florida Driver License.
A copy of your current social security, SSI, SSD, or public assistance benefit notification.
Enter Contact Information
Diagnosis & Household Information
Active treatment is defined as the period after positive diagnosis of cancer (with a diagnostic biopsy), and during which therapies are being administered, including surgical procedures to remove the cancer, chemotherapy or radiation. Active treatment does not include reconstruction surgeries or long-term hormonal therapies.
Please note: The Beautiful Gate funds are limited and applications are approved based on availability of funds.
Preference Information
I agree to terms & conditions provided by The Beautiful Gate Cancer Support & Resource Center. By providing my phone number and email, I agree to receive text and email messages from The Beautiful Gate Cancer Support & Resource Center.