APPLICATION CRITERIA

The Darren Daulton Foundation is committed to providing financial assistance to those who suffer from malignant primary brain tumors. If you or a loved one affected by one of these conditions needs assistance, please submit a written request to the Board as follows:

The Darren Daulton Foundation does not grant assistance based on age, race, religion, or gender.

Criteria:

1) Applicants must be a resident of Pennsylvania, New Jersey, or Delaware

2) Diagnosis of a malignant primary brain tumor
3) Currently receiving treatment for the diagnosis
4) Demonstration of household financial hardship due to diagnosis

5) Applicant must submit current medical pathology reports

Applicants MUST be a resident of Pennsylvania, New Jersey or Delaware at the time of submission of their application. Applicants can only have one APPROVED (up to $3,000.00 per Applicant) application per family every 365 days. All bills to be paid by the Foundation in connection with the grant must be submitted to the Foundation for payment within 60 days receipt of the grant. The Foundation reserves the right to deny payment of expenses which in the judgment and determination of the Board do not meet the mission of the Foundation. In such event, the Applicant will be notified and requested to suggest an alternate expense for payment.

· Diagnosis must be a malignant primary brain tumor
· Applicant must be living at the time the Board votes on the application

PATIENT CONTACT INFORMATION

First Name *

Last Name *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Date Of Birth * +

Referred by: *

MEDICAL INFORMATION

IMPORTANT - Please attach an electronic copy of your pathology report or treating physician records that include tissue diagnosis for verification purposes.

Primary Physician's Name: *

Primary Physician's Phone Number: *

Hospital or Treatment Center *

Nurse/Social Worker *

Nurse/Social Worker Phone Number: *

*Please attach a pathology report and CURRENT full treatment note from your oncologist. Failure to do so will result in REJECTION of your grant request due to insufficient information to determine your medical eligibility to qualify for consideration of a grant. MRI and CT scan records are not sufficient for evaluating your medical eligibility to qualify for consideration of a grant.*

PERSONAL AND FAMILY INFORMATION

Marital Status *

How many adults are living in your household? *

How many children are living in your household? *

Are you currently employed? *

If so, please list your employer. *

Type of Health Insurance *

Level of deductible and total out of pocket expenses *

INCOME

Employer: *

Current Monthly Net Income: *

Pay Period (weekly, biweekly, etc.) *

Current Checking Account Balance *

Current Savings Account Balance *

Current Monthly Social Security Retirement Income (if eligible) *

Current Monthly Social Security Disability Income (if eligible) *

Current Monthly Retirement Pension *

Life Insurance *

Current Monthly Rental Property Income *

Financial Gifts (i.e., from family, friends, fundraiser held on your behalf) *

Current Monthly Unemployment Compensation *

Current Monthly Workers Compensation *

PERSONAL AND HOUSEHOLD EXPENSES

Current Monthly Student Loans: *

Current Monthly Mortgage(s)/Rent *

Current Monthly Maintenance *

Current Monthly Electric *

Current Monthly Gas *

Current Monthly Oil *

Current Monthly Telephone *

Current Monthly Water *

Current Monthly Sewer *

Current Monthly Real Estate Taxes *

Current Monthly Personal Property Taxes *

Current Monthly Automobile Payment *

Current Monthly Health *

Current Monthly Insurance (list type, i.e. auto, homeowner's, life, healthy) *

Frequency of Insurance Payment (weekly, monthly, quarterly, etc.) *

Credit Card (monthly payment due and total balance due) *

Food expenses per month *

Current Monthly Other Expenses: Please list and specify amount(s) owed per month and total balance due *

MEDICAL RELEASE

Please read and e-sign below. Make sure to have this medical release e-signed and dated by a witness (an adult 18 or older other than yourself). I understand and grant my permission to all my doctors, social workers, clinics and hospitals to release all healthcare and billing information relating to my treatment and care for malignant primary brain tumor and other related health problems to the Darren Daulton Foundation. I also grant my permission to discuss the above information with any designated representative of Darren Daulton Foundation by phone. The Darren Daulton Foundation agrees that all medical information will remain confidential and any reports written about the program will not use any participants’ names without their express permission. I specifically authorize the release of all my healthcare and billing information in your organization’s possession. The purpose of my request is to assist the Darren Daulton Foundation in determining my eligibility for financial assistance. This Release and Authorization shall expire twelve (12) months from its execution if not revoked prior thereto. The Darren Daulton Foundation will not disseminate or release these medical records to any outside source without first obtaining prior express consent. I understand and agree that fulfillment of assistance may result in publicity whether or not the Darren Daulton Foundation actively takes steps to publicize its service. I understand and recognize that the granting of any service and the participation of any person in the assistance is contingent upon approval by the Darren Daulton Foundation. I also understand that there is a limit to the number of services that I will receive, depending on the type and cost of service being requested and offered. I understand and agree that no promises or assurances whatsoever have been made to me by any representatives of the Darren Daulton Foundation regarding the assistance I am requesting.

The Darren Daulton Foundation may hold events and fundraisers throughout the year to raise money to fund the primary objectives of the foundation: to help individuals and/or families endure the staggering cost of malignant brain tumor treatment. People continue to support us because they want to see their money find its way to the people who need it the most. We need your help to put a face and a name to that reality. To this end, we will only use your photo, your name, and your submitted story. If your application is approved, the Darren Daulton Foundation may also use a brief description of how the assistance that you received has helped you. This will facilitate communication with our donors and help in attracting more contributors. Please acknowledge this notice-release by e-signing below:

I hereby acknowledge that if granted financial assistance, the Darren Daulton Foundation may use my name, photo, background and story in PR and marketing materials which will include, but not be limited to, its newsletters, website, mailings and general informational brochures.

Patient's name: *

Patient's e-signature *

Date: *

By entering your name in the above box and checking the box you are agreeing to the conditions stated above *

Accept

Witness *

Witness e-signature *

By entering your name in the above box and checking the box you are agreeing to the conditions stated above *

Accept

Name of Spouse, Parent or Guardian completing application if patient is unable to do so *

BE SPECIFIC: Grant amount requested and purpose(s) for which it will be used *

Please note: The Darren Daulton Foundation pays companies directly from bills and/or statements received once financial assistance is approved. Upon approval you will be required to provide an invoice(s) for payment(s) which is made directly to the service provider.

The Board has no way of knowing you except through this application. Therefore, we would like you to tell us your ‘story’ and include a photo of yourself (or family) so that we might better understand your need for our assistance.

If you are unable to electronically upload requested medical documentation that have been requested within this application, please mail to:

The Darren Daulton Foundation
c/o Brett Datto
1339 Chestnut Street Suite 500
Philadelphia, PA 19107 *