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Patient Assistance Program Application

If you would like to apply for assistance from the Go Jen Go Foundation, please fill out the form below completely and accurately.  All information submitted is considered completely confidential and will not be shared with any third party. 

Grants awarded based on financial need for assistance with daily living expenses including housing, utilities, transportation, groceries and necessities. Medical expenses are not eligible.

Eligibility Criteria

– Diagnosed with breast cancer within the last 24 months
– Reside or receive treatment within the Greater Charlotte Area
– Currently in active treatment as defined by the Go Jen Go Foundation

Visit our Frequently Asked Questions to learn more about our application process, qualification details and more.

Applications for assistance are reviewed twice a month. You will have a final decision within 3 weeks of your application submission.

If you have further questions, please email our program manager at [email protected].

1 Step 1
Race/EthnicityOptional
Are you currently undergoing active treatment?surgery, chemotherapy, and/or radiation
Employment Status
If not currently working, describe reason:Select all that apply
Are you working with a Social Worker or Patient Navigator?
May we contact your Social Worker or Patient Navigator on your behalf?
Please select the form of assistance most helpful in your current circumstancesSelect one
What is your Primary financial need right nowSelect one
I hereby attest that the information provided in this application is true, accurate, and complete and that I am the person who is the subject of the application or have been authorized to act on behalf of the applicant.
Relationship to Patient:

Applications for assistance are reviewed twice a month. You will receive an update or request for additional information typically within 3 weeks of your application submission. 

Questions can be directed to [email protected].

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1 Step 1
Race/EthnicityOptional
Are you currently undergoing active treatment?surgery, chemotherapy, and/or radiation
Employment Status
If not currently working, describe reason:Select all that apply
Are you working with a Social Worker or Patient Navigator?
May we contact your Social Worker or Patient Navigator on your behalf?
Please select the form of assistance most helpful in your current circumstancesSelect one
What is your Primary financial need right nowSelect one
I hereby attest that the information provided in this application is true, accurate, and complete and that I am the person who is the subject of the application or have been authorized to act on behalf of the applicant.
Relationship to Patient:

Applications for assistance are reviewed twice a month. You will receive an update or request for additional information typically within 3 weeks of your application submission. 

Questions can be directed to [email protected].

keyboard_arrow_leftPrevious
Nextkeyboard_arrow_right
FormCraft – WordPress form builder
 
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The Go Jen Go Foundation is registered as a 501(c)(3) tax-exempt charity foundation. EIN 27-0895849.

Our mailing address:  7804 Fairview Rd, #217  |  Charlotte, NC  28226
704-774-6700

Copyright © 2024 Go Jen Go

This website was designed and built by a cancer survivor.