Jordan’s Dream Fund for Clinical Trials Application - Patient Form

PATIENT INFORMATION

Patient's Name

First

Last

Date of Birth

Patient's Address

City

State/Province

Zip/Postal

Country

Patient's Phone

Patient's Email

Type of Sarcoma

Date of Diagnosis

Does the patient have health insurance?

Yes

No

REPRESENTATIVE INFORMATION (please fill out this section if person completing the application is different than the patient):

Representative's Name

First

Last

Representative's Address

City

State/Province

Zip/Postal

Country

Representative's Phone

Representative's Email

Relationship

PREVIOUS CANCER TREATMENT: (check all that apply)

Chemotherapy:

Yes

No

Radiation:

Yes

No

Surgery:

Yes

No

Immunotherapy:

Yes

No

Previous Clinical Trial:

Yes

No

If yes, which types of chemotherapy:

HOUSEHOLD INCOME INFORMATION

Is patient currently employed?

Yes

No

Place of Employment:

INCOME SOURCES

(please select all that apply

Salary/Wages

Social Security (retirement) SSI

SSD (disability) Unemployment

Public Assistance

Short-term disability

Other (please specify):Other (please specify):

FINANCIAL ASSISTANCE REQUESTED

Ground Transportation Total: Mileage / Parking / Tolls Total:

(Uber, Taxi, Lyft, Rental, Train)

Lodging Total:

Air Travel Total:

Other (please specify):

Total Amount Requested (up to $5,000):

TOTAL ANNUAL HOUSEHOLD INCOME:

NUMBER OF PEOPLE IN HOUSEHOLD:

HOW DID YOU LEARN ABOUT THIS FUND?

Internet

Physician Nurse

Social Worker Support Group

OtherOther

Jordan’s Dream Fund for Clinical Trials Application – Patient Form