SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
CLIENT APPLICATION FORM
Candidates for financial assistance must have been diagnosed with breast cancer, and must have a treatment plan and be pursuing that
treatment plan or recovering within 2 months of the end of the treatment plan. If you have a diagnosis of metastatic breast cancer, are
undergoing any form of treatment, and the disease or treatment prevents you from working, you may be considered eligible for
If you have completed surgery, chemotherapy, and/or radiation for primary breast cancer, are considered to have no evidence of
disease (NED), and are now taking adjuvant Tamoxifen, Arimidex or similar hormonal treatment on a long-term basis, you are no
longer considered to be in treatment for active breast cancer and are no longer eligible for assistance. If you stop treatment for any
reason against your oncologist’s advice, you will no longer be eligible for assistance.
Thank you for applying to Solano Midnight Sun Foundation (SMSF). Please read the following instructions before beginning the
1. Complete pages 2-5 of the application. Be as specific as possible with regard to income and expenses, savings, and other forms of
assistance to which you may have access. Please initial the bottom of every page where indicated.
2. Pages 6 and 7 are two copies of an authorization for release of your medical information by your doctor. Fill this form out
completely, and give one copy to your doctor (oncologist, surgeon - whomever you consider to be the head of your medical team).
This form tells your doctor that you give him/her permission to provide information about you to SMSF and should be kept in
your file. Please send one copy to SMSF along with your application.
3. Have your physician complete page 7, which will tell SMSF about your breast cancer diagnosis and treatment plan. He/she may
complete the form and return it to you, or complete it and mail it directly to SMSF.
4. Submit your application to SMSF by mail or fax. Please note: Your application will not be processed until complete, including
receipt of the physician report (page 7). CRITERIA FOR ELIGIBILITY ovides support for individuals living in Solano County who ar ovides support for e going thr individuals living in Solano County who ar e going thr east cancer east cancer eatment, and whose income and/or expenses ar income and/or e significantly impacted by tr expenses ar eatment. SMSF e significantly impacted by tr eatment. SMSF eserves the right to verify income, expenses, and treatment plan by r equesting the following information. eatment plan by r VERIFICATION CONDITIONS Identification
Must provide proof of identification. Picture ID, CDL, California ID, passport, employment or school
ID, or other acceptable identification and social security card.
Must be a resident of Solano County to be eligible for SMSF support. Proof of location of residence
by rent receipt, mortgage payment receipt or contract, or note from landlord; utility receipts, turn-off
notice, late notice, eviction notice, fore-closure notice, 3 day notice to quit, etc.
Must provide verifiable income information for pre-treatment and during treatment. Earned and
unearned income for spouse or other responsible persons living in the home. Medical statement
Must be in active treatment to receive SMSF support. Current diagnosis, prognosis, surgery date, and
treatment plan with date and signature of treating physician
Non-shelter expenses
Must provide information about credit payments, car payments, child care, child support, cable,
furniture storage, health club, other legal obligations for spouse or other responsible persons living in
Vehicles Personal Items Real estate **Please initial the bottom of every page of this application** Date of Application SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
DEMOGRAPHIC INFORMATION Name:
Address: City, State Zip: Phone number: Home:
MARITAL STATUS (please circle) 1. Married CHILDREN Name SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
What medical insurance do you have? (Private, Medicare, MediCal, BCCTP, etc.)
Current breast cancer diagnosis – please include stage and treatment plan (in your own words)
Tell us your reasons for making this application:
Did someone help you with this application? No Yes Name:
Please list your physicians below, including name and phone number:Medical Oncologist:
Please provide us with an emergency contact. The person you list should be someone that you are in contact with on a
regular (daily or weekly) basis that we can call if we are unable to reach you. Name:
Please use this space to add any comments or information you would like to tell us:
SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
WORK HISTORY Most recent employer:
If not currently working, date last worked:
CURRENT INCOME Monthly amount Please indicate if you have applied for any of the following. Please indicate if you have applied for Circle “accepted” if you ar cle “accepted” if you ar eceiving funding, “pending” if your application is in pr eceiving funding, “pending” if your ocess, or application is in pr ocess, or “denied” if you have been denied for that pr “denied” if you have been denied for
8.In-home care/In-Home Supportive Services
TOTAL AVAILABLE MONTHLY INCOME (add lines 1-22 together): SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
Are you receiving funds/loans/donations, etc. from any other social services agencies in your County? No Yes
If yes, list all agencies and dates and amounts of last aid (use a separate sheet if necessary):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MONTHLY EXPENSES
1. Medications (related to breast cancer treatment only)
1. Medical co-payments and/or share of cost
1. Other: TOTAL OF ALL MONTHLY EXPENSES (Add lines 1 through 17 together):
Please check this box if you would like to be referred to other agencies for possible assistance. Referrals may result in
sharing your information between SMSF and other agencies.
By signing below, I agree that the above information is true and correct. APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
Agency/Individual From Whom Information is Requested (e.g., your physician)
hereby authorize you to release to Solano Midnight Sun Foundation, non-profit organization (20-8124921) specific information requested by them which I cannot provide concerning:
This information is needed to determine my eligibility for assistance from Solano Midnight Sun Foundation (SMSF) I have read this form and have agreed to its request prior to my signing. Note: Provide this form to the physician or other agency from whom you are requesting the release of information to Solano Midnight Sun Foundation. SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
APPLICANT AUTHORIZATION FOR RELEASE OF INFORMATION
Agency/Individual From Whom Information is Requested (e.g., your physician)
hereby authorize you to release to Solano Midnight Sun Foundation, non-profit organization
(68-0354961) specific information requested by them which I cannot provide concerning:
This information is needed to determine my eligibility for assistance from Solano Midnight Sun Foundation (SMSF) .I have read this form and have agreed to its request prior to my signing. Note: Provide this form to the physician or other agency from whom you are requesting the release of information to Solano Midnight Sun Foundation. SOLANO MIDNIGHT SUN FOUNDATION
795 Alamo Drive, Suite 106 · Vacaville, CA 95688
Phone: (707) 469-9909 Fax: (707) 320-0018 Website:
PHYSICIAN REPORT
The individual listed below has requested assistance from Solano Midnight Sun Foundation (SMSF) and has stated that s/he is unable to work or is unable to work at pre-treatment level. A signed release for the requested information is attached.
Please complete this form and return it by: ____________ (date)
Attn: Director of Client Services Solano Midnight Sun Foundation 795 Alamo Drive, Suite 106 Vacaville, CA 95688 SECTION I SECTION II – T SECTION II – O BE COMPLETED BY O BE COMPLETED BY YOUR PHYSICIAN
Pertinent pathology results (attach copy of report if available):
Is patient’s condition suitable for Is patient’ employment? s condition suitable for employment? Y What level of employment activity is suitable for patient? What level of employment activity is suitable for patient? Part-time ____ hours per week Projected date patient can r eturn to work at pr ojected date patient can r eturn to work at pr eatment level: Planned surgeries – list date and expected date of recovery: Planned surgeries – list date and expected date of r Other planned tr eatments (chemo, radiation, etc.) – list pr planned tr ojected end date: eatments (chemo, radiation, etc.) – list pr