Name Eligibility Criteria Applicant must be a current Georgia resident. Applicant must have a current cancer diagnosis; may be undergoing treatment or recently completed chemotherapy and/or radiation. Application requirements must be completed by the applicant or an immediate family member. Applicant must submit completed application along with supporting documentation. Scan all documents and email to joline@nancyfalcofund.org Application must include proof of relationship such as Birth Certificate, Marriage license or Power of Attorney. Please note that proof of relationship is only needed if someone other than the person with cancer is filling out the application. First name * Last name * Birthday * Email Address * Phone * Address * Who Completed Application? * Self - I completed this application myself Spouse Child Legal parent Power of Attorney Other How did you hear about the Nancy Falco Fund? * Website Media Friend Other I understand that if I am selected as a finalist I will need to provide my Social Security Number. * Yes No If I am picked as a finalist I understand this requires me (or representative of the family) to attend the Dancers Unite Against Cancer event. If you cannot attend due to medical treatments, you can send a representative (relative or friend) on your behalf. * Yes No I understand that my completed application along with all supporting documentation to be considered. * Yes No Scan and email all documents to joline@nancyfalcofund.org. I understand that the Applicant must currently be living in order to qualify. However, if the fund winner passes prior to the Dancers Unite event, then all funds will be awarded to the Power of Attorney. * Yes No Does the applicant have a current cancer diagnosis? * Is the applicant currently undergoing treatment or have they recently completed chemotherapy and/or radiation. * I will be emailing a letter from my Doctor stating diagnosis, medical opinion, and treatment plan. * Yes No Scan and email all documents to joline@nancyfalcofund.org. Please compile the final documents * Prior year parental or legal guardian tax return, Social Security documentation, or applicable income information Prior year tax return if applicant is employed Scan and email all documents to joline@nancyfalcofund.org. Are you currently employed? * Yes No If employed, please provide company name. * Provide a list of current expenses that need payment assistance. * Include a 500-word essay detailing your cancer story and current hardship * Including but not limited to medical expenses, notice of loss of income due to illness Provide three personal references, family members cannot be included. * Comments / Questions *