TJ & Friends Foundation, Inc.
Ride to Live, Live to Ride, Live Strong

APPLICATION FOR DONATION
Submit this completed application along with the required documentation to PO Box 6161, Elberton, GA 30635.
Faxed documents WILL NOT be accepted.


_______________________________________________________________________________________________________

    Name _________________________________________________________________

 
     Physical address:

     _________________________________________________________________________________________     ______________________________    

     Street                                                               City                                State                                 Zip                                                County 

     Mailing address:

     ______________________________________________________________________________________________________________

     Street                                                                                       City                                                           State                           Zip

Contact numbers:

     ______________________________________________________________________________________________

     Home phone                                                                                                                      Cell phone

     Email address: ________________________________________________________________________

_______________________________________________________________________________________________________

Cancer diagnosis:

 

     Type of cancer: ___________________________________________________________________________

     Date of Diagnosis:  ________________________________________________________________________

_____________________________________________________________________________________________________

Statement of need:

     Describe your need for this monetary donation.

     ________________________________________________________________________________________

     ________________________________________________________________________________________

     ________________________________________________________________________________________

     ________________________________________________________________________________________

       
______________________________________________________________________________________________________

 Statement of involvement in your community:

     Describe your involvement in the community in which you live in.

     ________________________________________________________________________________________

     ________________________________________________________________________________________

     ________________________________________________________________________________________

     ________________________________________________________________________________________

     

_______________________________________________________________________________________________________

Please attach following documents with your application. Failure to submit these items will classify your application NOT COMPLETE,
therefore will not be reviewed until the recquired documents are submitted.

Proof of cancer diagnosis:

_____________ (initial) You must attach a signed and notarized statement from your attending physician, currently treating you for cancer,
confirming cancer diagnosis. *** WE DO NOT ACCEPT PATHOLOGY REPORTS OR OTHER MEDICAL DOCUMENTS!

Proof of residency:

_____________(initial) You must attach a copy of local tax documents, or a signed and notarized statement from you landlord proving you
 have been a resident of one of the following counties for at least one year prior to your diagnosis; Elbert, Hart, Franklin, Madison, Lincoln,
Oglethorpe, or Wilkes County. *** WE DO NOT ACCEPT STATE OR FEDERAL TAX DOCUMENTS!


Proof of citizenship to the United States:

______________(initial) You must attach a certified copy of your birth certificate, or other documentation in order to prove that you are a
citizen of the United States.


Medical informaiton release:

________________(initial) I authorize the release of my medical informaiton to the TJ & Friends Foundaiton, Inc. for the purpose of verifying
my cancer diagnosis in order to complete my application.



By signing below, I promise that all information contained in and attached to this application is true. I authorize and release this
information for the sole use of TJ & Friends Foundaiton, Inc. in order to receive the donaiton.

 If applicant is under age 18 or elderly, a family member or guardian signs as witness.


__________________________________________                                            _________________________________________
              Signature of Applicant                                                                                               Witness (if needed)

_______________________________________________
                               Date