Application Form - The Singletons

Contact Information

Name

First Last

Date of Birth

Primary Language?

Date of application

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone Number

Email Address

Preferred method of contact

Relationship Status

Married

Domestic Partnership

Divorced

Widow or Widower

Single

Dependents

How many children you have?

Please List Gender and Age of every child in the household.

Emergency Contact Information

Name

First Last

Phone Number

Relation

Program Specifics

The Singletons has a meal program. Do you or any of your children have food allergies?

Personal Profile

If given the opportunity, would you be interested in media opportunity?

How were you referred to The Singletons? / How did you hear about us?

When were you diagnosed?

What is your Cancer diagnosis? Stage?

Who is your Oncologist?

Where are you receiving treatment?

The Following information is for statistical purposes only and will not affect your eligibility to receive services from The Singletons. This information is compiled and used in grants to fund The Singletons Program. Certain Statistical information may also be used in The Singletons’ literature, on their website or to educate the public about the population that The Singletons serves.

Do you own your home or rent?

If you do rent, do you qualify for subsidized housing?

What is your living situation? Living with friends or family?

Do you receive any forms of assistance? i.e. Food Stamps, Cash Assistance, Disability, etc.

Do you receive child support?

Are you currently working? If so, where?

What is your racial or ethnic heritage?

Have you served in the U.S. Military or Armed Forces?

Comments

This field is for validation purposes and should be left unchanged.