Please complete the questions below. Once completed, you will receive a welcome email and/or call within 1 week of submission (be sure to check your spam folder if you do not receive it). If you are completing this on behalf of someone else be sure to enter the CANCER WARRIOR’S address and the phone/email address for the person who would like to receive emails about coordinating services on their behalf (either the warrior or another designated contact person).

Lifestyle Assistance Fund is for any single parent with dependent children in active cancer treatment.

lifestyle assistance fund application

Contact Person Name

Insert the name of the contact person that we will be sending correspondences to for the Warrior's family to coordinate services.

First Name

Last Name

Contact Person Email

This is the email we will be sending correspondences to for the Warrior's family to coordinate services.

Phone

This is the number we will need on file to reach the Warrior's family.

(###)

###

####

Emergency Contact Name

First Name

Last Name

Phone

Emergency Contact Information

(###)

###

####

Emergency Contact Email

Employment

How long have you been employed?

Are you willing to take a drug test?

Religious Preference

What is your relationship with the Cancer Warrior?

Cancer Warrior's Name

First Name

Last Name

Cancer Warrior's Birthday

YYYY

Cancer Diagnosis

Please give a brief explanation of the Cancer diagnosis.

End of Treatment Date

If you don't have and end of treatment date or you don't know your end of treatment date then set the date for 3 months from today.

YYYY

Treating Facility

Cancer Warrior's Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Number in Household

Dependents Age?

Please include all ages of dependents

Photo Release Approval

May we use your photo on our website or news letter?

Yes

Background Check

By selecting 'Yes' applicant verifies that they are aware that the Lone Warrior Foundation may conduct a background check on Lifestyle Fund Applicants.

Yes

Hold Harmless Release Form

Please review and acknowledge acceptance of the release below. The Person executing this Application is authorized by the Beneficiary to do so. RELEASE THIS IS A LEGALLY BINDING DOCUMENT. READ IT CAREFULLY BEFORE SIGNING IT. _____________________________________________(the “Beneficiary”) and Lone Warrior Foundation, Inc. (“Lone Warrior”) enter into this Release (“Release”) on the date it is last signed by them. WHEREAS Lone Warrior is a charitable, not-for-profit organization serving Beneficiary and other families battling cancer; and WHEREAS Lone Warrior has secured the commitment of other businesses (the “Participating Organizations”) to provide their goods or services, free of charge or at a discount, to Beneficiary; and WHEREAS Lone Warrior is willing and able to refer the Participating Organizations’ services to Beneficiary subject to the terms and conditions of this Release; and WHEREAS Beneficiary wishes to receive and benefit from the goods or services of one or more Participating Organizations’: NOW THEREFORE, in consideration for the above recitals, which are true and fully a part of this Release, of the promises and covenants below, and of other, valuable consideration, the receipt of which is hereby acknowledged: 1. Beneficiary will hold Lone Warrior harmless from any claim, demand, or cause of action, by whomever and wherever brought, that arises out of or is in any way related to a Participating Organization providing services to Beneficiary; and indemnify Lone Warrior for any monetary assessment or cost, including attorneys’ fees, imposed on or incurred by Lone Warrior as a result of any such claim, demand or cause of action. 2. The Beneficiary covenants not to sue or make any demand against Lone Warrior for any loss, harm, or injury they may incur that arises out of or relates to services provided to Beneficiary by any Participating Organization, and further releases and forever discharges Lone Warrior from any and all claim, demand, or cause of action, in law or equity, known or unknown, fixed or contingent, under any theory whatsoever, that they may ever have against Lone Warrior that arises out of or relates to the services provided to Beneficiary by any Participating Organization. 3. Additional terms and conditions: a. This Release is governed by Florida law. Any litigation arising out of or related to this Release will be heard by such Florida State Court in and for Duval County as has jurisdiction, and the Parties hereby subject themselves to that Court’s jurisdiction. b. This Release binds and insures to the benefit of the Parties thereto, their officers, directors, affiliates, successors and assigns. c. Nothing in this Release creates any right in favor of any person or entity other than the Parties. d. Nothing in this Release may be construed to create a partnership, joint venture, or any relationship other than that clearly apparent from the plain terms of this Release. e. Neither Party may assign its rights or delegate its duties under this Release except with the other party’s written consent, which consent may not be unreasonably withheld or delayed. f. Where necessary to enforce the Parties’ intent under this Release, its provisions are meant to survive its termination. g. This Release may not be amended except by written Release signed by both Parties.

Hold Harmless Release Form Signature

Please enter your first and last name below as your virtual signature. The Person executing this Application is authorized by the Beneficiary to do so.