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Live Big Memory Trip Application

Libby's Legacy Breast Cancer Foundation (LLBCF) provides patient advocacy and wish granting services to Central Floridian, Stage IV (metastatic) breast cancer patients. LLBCF uses the following information to help determine services needed by Stage IV breast cancer patients. LLBCF will not use the following information for any purpose except to qualify patients for our free services. All information is kept confidential, unless otherwise stated.

Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address Address Line 2 City ZIP Code
Home Phone*
Cell Phone
Work Phone
Best number to call
- Home
- Work
- Cell
Best time to call
- Morning
- Afternoon
- Evening
Date of birth*
MM slash DD slash YYYY
Email*
Preferred method of contact
- Email
- Phone call
- Letter
Have you received wish granting from another organization?*
Please describe
Employement Information
Are you currently employed?*
Who is your employer?
Do you work
Emergency Contact
Name*
First Last
Relationship*
Phone*
Email
Service Eligibility & Release of Information Form
In order to qualify for a trip or other wish through LLBCF an individual must be diagnosed with Stage IV breast cancer
Diagnosis of stage*
Date of diagnosis*
MM slash DD slash YYYY
Date treatment began (or will begin)*
MM slash DD slash YYYY
Name of Physician(s):
In order for LLBCF to provide services we must confirm diagnosis and treatment status with your physicians. Please provide the following information:
Primary care provider*
Address
Street Address Address Line 2 City ZIP Code
Phone*
Oncologist*
Address
Street Address Address Line 2 City ZIP Code
Phone*
After submitting this form, please visit us at our office to complete and sign this application
I have read and understand the above and declare the information furnished by me is true and complete to the best of my knowledge. I consent to the exchange of information between Libby’s Legacy Breast Cancer Foundation and other community agencies to provide needed services. Libby’s Legacy Breast Cancer Foundation does not discriminate against any person because of their race, creed, religion, sexual orientation, gender, age, or income.
Upload Agreement/Release of Liability Here
Max. file size: 512 MB.
Please download, read, complete and sign our AGREEMENT/RELEASE OF LIABILITY below and upload here to expedite your submission.
Name
This field is for validation purposes and should be left unchanged.

Please download, read, complete and sign AGREEMENT/RELEASE OF LIABILITY Upload this along with your online submission above or bring it in with you when you visit us to complete and sign the application.

As part of our ongoing need for grants and funding, it is frequently necessary that we provide statistical information to our funding sources. For this purpose, we would like to ask that you provide us with the following information. Please understand complete confidentiality will be maintained.

Click here to fill out an optional Statistical Analysis Survey

Live Big Memory Trip Application

Employement Information

Emergency Contact

Service Eligibility & Release of Information Form

Name of Physician(s):

After submitting this form, please visit us at our office to complete and sign this application

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