Quality of Life Grant Application

The Power of Will Quality of Life Application

Eligibility Requirements for The Power of Will Quality of Life Application

The patient must be an adolescent or young adult (AYA) between the ages of 15-39 with a sarcoma diagnosis who is either actively in treatment or within one year of completing treatment.
The application must be completed by a member of the patient’s treating oncology team such as a physician, social worker, nurse practitioner, nurse, etc.

Quality of Life Grant Application

"*" indicates required fields

Contact Name*

Contact Email*

Treating Medical Professional Name (First and Last)*

Treating Medical Professional Email*

Treating Medical Professional Phone*

Medical Professional Type*

Physician

Social Worker

Nurse Practitioner

Nurse

Other

Treating Hospital or Medical Center*

Patient Name (First and Last)*

Patient Date of Birth*

Patient Gender*

Patient's Preferred Pronouns*

Sarcoma Diagnosis*

Actively in Treatment?*

Yes

If no, when was the patient last treated for their diagnosis? (Month/Year)*

Patient's Quality of Life Goals*

The Power of Will is invested in understanding the current needs of AYA sarcoma patients so that we may better serve them as we continue developing our Quality of Life Program. We would love to know what a grant from our organization would mean for your patient. Please tell us about your patient and what quality of life means to them with a sarcoma diagnosis (up to 500 words).

Signature*

By signing this application, I attest that all information is accurate and truthful.

Consent*

By signing this application you are attesting that you have spoken to your patient (or their parent/guardian if your patient is under the age of 18), and that your patient has agreed to allow their medical team and The Power of Will to discuss their case.

I agree

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The Power of Will, Inc.
Box #196
300 North Dean Rd., Suite 5
Auburn, AL 36830

info@thepowerofwill.org

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The Power of Will is a 501(c)3 nonprofit. Tax ID #85-3864250