Application for Assistance Step 1 of 7 - 1. ELIGIBILITY CRITERIA 14% REACH US – Pilbara Inc. has been founded to assist those residing within the Pilbara region, whilst undergoing Cancer treatment, by providing ancillary support services which are readily available to those living within Metro areas. Ancillary support is intended as a short-term practical assistance, when treatment for cancer is impacting a person’s (or their families) capacity to remain independent at home. REACH US – Pilbara Inc. is solely funded through community donations and receives no government support. As such, the value of funds available at the time of an assistance request may fluctuate from time to time and will be factored in when considering the application. Support services cannot be provided on an ongoing basis. The extent of ancillary support is limited both in value and to the services detailed within Section 3. REACH US – Pilbara Inc. will engage and pay the provider directly upon submission of an invoice when the services are complete. Please note cleaning and gardening services are provided on a maintenance only basis, we are unable to provide full yard cleans or vacate level cleaning of houses. A cancer diagnosis is not an automatic approval of a request for support, eligibility and availability of resources at the time of application will be assessed within the context of other support services and family resources available to individuals. To be eligible for assistance, applicants must be undergoing active treatment or management of a confirmed and current cancer diagnosis, be residing within the Pilbara Region, and be experiencing hardship as a result. Are you completing this application on behalf of someone?YesNoName of person completing this application(Required) First Last If you do not have an electronic signature, please type your name.Relationship to Patient:(Required) How/Where did you hear about Reach Us? Patient Name(Required) Dr.MissMr.Mrs.Ms.Prof.Rev. Title First Name Surname Patient Date of Birth(Required) Patient Gender(Required) Does the patient identify as Aboriginal or Torres Strait Islander?(Required) Patient Address(Required) Street Address 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 Patient PhonePatient Email(Required) Emergency Contact Name(Required) First Last Emergency Contact PhoneRelation to Client(Required) Name of cancer type(Required) Diagnosis (please be specific):(Required)Where was the patient diagnosed? Stage of disease:(Required) Treatment type:(Required) Treatment Centre(Required) Date of diagnosis(Required) MM slash DD slash YYYY Treatment Start Date(Required) MM slash DD slash YYYY Would you like to add any further information?(Required) Yes No Other information Name of Doctor(Required) Medical Practice(Required) Please include information on what services Reach Us can assist with - if unknown, please leave blank. This application will be assessed based on the level of information provided. Please note – this application for assistance is not an emergency service. Provision of the requested services may take up to 4 weeks from the date of verification. If approved: Our Support Co-ordinator will be in contact with you to discuss the services available and match you to a local service provider. Payments are made directly to service providers upon completion of the services. If not approved: The applicant will be notified via email that the Application for assistance was unsuccessful. Although due care has been taken to ensure the quality and legitimacy of service providers, REACH US – Pilbara Inc. and it’s authorised representatives accept no responsibility or warranties whatsoever (whether expressly or implied, contractual or statutory) for the quality, fitness, or suitability of any service provided by REACH US – Pilbara Inc. through its service providers or the service providers themselves. Therefore, by accepting the provision of the requested services, you acknowledge and agree to utilise said services at your own risk. Please email your application to: email@example.com REACH US – Pilbara Inc. must be notified if the applicant’s status changes during the support service delivery program.