Outer Banks Cancer Support Application | Interfaith Community Outreach

General Information

Name*

First MI Last

Birth Date*

Identification Type*

Identification Number*

Race*

American Indian
Asian
Black
Latino
Pacific Islander
White/Caucasian
Other

Phone*

Email Address*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Physical Address*

Street Address Address Line 2 City State ZIP Code

Past Mailing Address

Street Address Address Line 2 City State ZIP Code

Township*

Family Status*

Single
Married
Divorced
Separated
Widowed

Spouse Name

First Last

Spouse Birth Date

Medical Information

Type of Cancer*

Date Diagnosed*

Physician*

Treatment Center*

Other person(s) living with you:

Name

First Last

Birth Date

Age

Relationship

School

Name

First Last

Birth Date

Age

Relationship

School

Name

First Last

Birth Date

Age

Relationship

School

Name

First Last

Birth Date

Age

Relationship

School

Assistance

Special Needs*

Type of assistance you need today and reason?*

What have you done to address these issues?*

What other agencies have you contacted? When?*

Why this request is considered a temporary gap service / What will be different next month?*

Who referred you / How did you hear about us?*

Social Service Assistance

Currituck Social Services
Dare County Social Services
Health Department

Do you receive help from any of the following programs?

Medicaid
NCHC
WFFA
Food Stamps
Section 8 Housing
WIC
SSI / Disability
EIC
Other

Name of DSS Caseworker

First Last

Phone

Total Household Income

Weekly Income $*

Monthly Income $*

Child Support / Other $*

Present Employer*

Supervisor

Employer Address

Employer Phone

Profession Type

Employment Type

Full Time
Part Time
Temporary
Seasonal

Past Employer*

Past Supervisor

Past Employer Address

Past Employer Phone

Last Date Worked

Name of Bank*

Checking Balance*

Savings Balance*

Expenses

Mortgage/Rent*

Car/Transportation*

Power/Gas/Water*

Food*

Other (cell, cable, etc.)*

List "Other" Expenses

Are you a member of a local church?*

Yes
No
N/A

Have you applied to the ICO for assistance in the past?*

Yes
No

Agreement & Signature

I certify that the information on this form is true and correct. Falsified information will result in denial of assistance. I give the Interfaith Community Outreach (ICO) permission to verify any information necessary to determine my eligibility for Emergency Assistance. I authorize the ICO to discuss my household's situation with members of Dare and Currituck County DSS, Food Pantry, Hotline, Health Department and any other individuals or organizations necessary to determine the need and identify appropriate assistance. I understand that there are regulations protecting the confidentiality of authorized information to verify assistance received or denied. I hereby acknowledge that this consent is truly voluntary and is valid for 180 days. I understand that I may revoke this consent at any time except to the extent that information has already been released before I revoke it.

Signature*

Date*

Comments

This field is for validation purposes and should be left unchanged.

Cancer Outreach Application

General Information

Medical Information

Other person(s) living with you:

Assistance

Total Household Income

Expenses

Agreement & Signature

Hours

Pages

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