Request Assistance Questions marked with * indicate required questions that cannot be left blank. I Have Wings proudly serves US citizens within the continental United States. The No One Goes Solo Programs were formed to help breast cancer patients focus on healing, time with family and returning to the workforce. Funding may be limited and available during active treatment. • Active treatment is defined as the period after a positive diagnosis of breast cancer, during therapy treatments, and/or surgery, chemotherapy, or radiation. • For the purposes of I Have Wings, active treatment does not include long term hormonal therapies (such as Tamoxifen, Arimidex , Femara and others). Thank you for applying for assistance with I Have Wings Breast Cancer Foundation. Have you been diagnosed with breast cancer?*YesNoPlease contact us via email at info@ihavewings.orgDo you live in Ohio, KY, or Indiana?*YesNoI Have Wings Breast Cancer Foundation continues to pray for all families and their medical teams as they work towards healing & comfort. We are currently overwhelmed by the daily requests for assistance from families struggling on various levels with breast cancer from all over the U.S. Unfortunately our small foundation is unable to help everyone at this time. Please continue to check back with us at a later time. Name* First Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country County Within Your StateEmail* Phone Number*Insurance Provider Medicare Medicaid Other None If Other Insurance Please SpecifyOncologist NameHospital Where You Receive TreatmentI Have Wings has permission to verify my medical status.Please click this button stating that you understand by submitting this request form, you are granting I Have Wings permission to verify your medical status with your doctor. Yes Diagnosis/Re diagnosis DateAnnual Household Incomeunder $10,000$10,000-$24,000$25,000 or moreHow Did You Hear About IHW? Friend Google Search Facebook Referral Other Including Yourself How Many Live In Your Household?12-34 or moreBriefly Describe The Type Of Assistance You RequireWhich gas station is nearest to you?BPShellSpeedwayKrogerWalmartWhich grocery is nearest to you?KrogerWalmartAldiComments - Please Provide Any Additional Information You Think May Be Helpful For IHW To Understand Your NeedsPreferred Method of Communication Email Phone In-Person
