Living Waters Financial Assistance Program Application for Florida Residents

PLEASE READ:

The Living Water Financial Assistance Program is for Florida Residents ONLY who were diagnosed with breast cancer through the Florida Dept. of Health Breast & Cervical Cancer Early Detection Program.

To review your request for financial assistance, please complete this application and attach the following document.

Current pathology report that includes your full name and date of birth. (YOU MUST be undergoing ACTIVE treatment such as Surgery, Chemotherapy or Radiation Therapy ONLY).

Active treatment includes any treatment that's currently being given to remove the cancer or reduce the risk of it coming back. This includes surgery, chemotherapy, radiation, and targeted drug therapy
Active treatment does not include long-term hormonal therapies that are taken to help stop the cancer from coming back.

Once we receive the above document, we will contact you for additional information within 72 hours.

Enter Contact Information

First Name *

Last Name *

Email *

Phone *

Address *

City *

State *

Postal code *

Diagnosis & Household Information

What active treatments are you undergoing? *

Surgery

Chemotherapy

Radiation

Targeted Drug Therapy

Did you receive your mammogram through the Florida Department of Health Breast & Cervical Cancer Early Detection Program. *

Yes

Please select the county where you received your mammogram:

Brevard
Broward
Duval
Escambia
Gadsden
Hillsborough
Jackson
Leon
Miami-Dade
Orange
Osceola
Palm Beach
Pasco
Pinellas
Putnam
Sarasota
Seminole
Volusia
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What is your cancer diagnosis? *

How many are in your household? *

Adults
Children (under 17)

What kind of assistance are you requesting? *

Rental/Mortgage Assistance

Utilities Assistance

Food/Personal Items/Other

Shelter (due to homelessness)

Other

Please note: The Beautiful Gate funds ARE LIMITED and applications are approved based on availability of funds.

Preference Information

What is your preferred contact method? *

Phone

What is your preferred call time?

Morning

Afternoon

Evening

What is your preferred language? *

English

Spanish

Other

May we contact your treatment facility to verify diagnosis? *

Yes

Upload required documents here: *

Click here to upload required documents from your computer (10MB or less):

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.