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Step 1 of 6 - Preliminary Information

About the STAC Grant

What is STAC? Students Together Against Cancer is a student-run non-profit dedicated to helping local cancer patients make ends meet by providing assistance with food and utilities. STAC is primarily funded by local fundraising events and community/federal donations and grants. To learn more about STAC and the individuals who have benefitted from the STAC Grant, visit teamstac.org.

What IS THE STAC GRANT? The STAC Grant is designed to help local cancer patients make ends meet by providing assistance with food and utilities. Recipients are eligible for a one-time $400 grant in the form of B&R Stores Gift Cards (valid at Super Saver and Russ’s Market) or utility payments (checks written directly to utility companies).

WHO IS ELIGIBLE FOR THE STAC GRANT? Indidividuals who meet the STAC Grant Criteria listed below are eligible:

Individuals must reside in or be receiving treatment in Lincoln, NE.
Individuals must have a household income at or below 250% of the current federal poverty level.
In all cases, the individuals will already be under the care of a physician with a treatment regimen in place at the time of application.

HOW DO I APPLY FOR THE STAC GRANT? To apply for the STAC Grant, fill out all of the required information on this application and submit. Verification of information provided may be required. Grant recipients must complete and sign Form W-9.

HOW WILL I KNOW IF I AM SELECTED AS A STAC GRANT RECIPIENT? Indidivuals who are selected to receive the STAC Grant will be contacted at the phone number or email address provided on their application. Selection will occur within 4 weeks of receipt of the application.

Questions? Email STAC at apply@teamstac.org.

Who is completing this STAC Grant application?*

I (the applicant) am completing this application for myself.

I am completing this application for a family member or friend (the applicant).

I am an employee or case manager from a treating physician's office completing this application on behalf of a patient (the applicant).

Other

If completing this application on behalf of the applicant, please provide your name and contact information below.

Name*

First Last

Phone Number*

Email Address*

Name*

First Last

Date of Birth*

Month

Day

Year

Gender*

Phone Number*

Alternate Phone Number

Email Address*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Preferred Contact Method*

Preferred Language*

Annual Household Income*

Please enter your total household income from all sources. If you file a Federal tax return, please enter your adjusted gross income as most recently filed.

Household Size*

Please enter a number from 1 to 100.

Total number in household dependent on income listed.

Recent Changes to Household Income

Please list any recent changes to your household income (e.g. loss of job, unpaid medical leave).

Required Document: Form W-9*

STAC requires all grant recipients to submit a signed W-9 prior to receiving grant funds. Please click here to download a blank W-9. Click "Choose File" below to upload your complete, signed W-9.

Max. file size: 300 MB.

Authorization to Request Proof of Income*

To verify your eligibility for the STAC grant, STAC may need to request copies of documents necessary to support the income information listed above (e.g. recent tax returns, pay stubs, dependent care, etc.). By checking the "I Agree" box below, you're giving STAC permission to request this information.

I agree.

Type of Cancer*

Treatment Location*

Treating Physician*

Physician/Office Phone Number*

Contact Authorization*

STAC may need to contact your treating physician or office to verify you meet the STAC grant criteria. This is an exchange of information protected by HIPAA Privacy rules and requires patient authorization. To submit this application and to be eligible for the STAC Grant, the applicant must agree to this potential exchange of information.

I agree.

Type of Assistance Requested*

The STAC Grant provides a total of $400 in assistance that can be allocated between the following categories. Please select one or more and enter the amounts below (totaling no more than $400).

Food Assistance (B&R Stores Gift Cards)

Utility Assistance (Documentation Required)

Food Assistance Amount

Please list the amount of food assistance (B&R Stores gift cards) requested. B&R stores gift cards are valid at Super Saver and Russ's Market. If no amount is entered, the default will be $400.

Utility Company 1 & Amount

Please provide the name of the utility and the amount of the bill you'd like the STAC Grant to help pay for. If no amount is entered, STAC will contact you.

Utility Company 2 & Amount

Please provide the name of the utility and the amount of the bill you'd like the STAC Grant to help pay for.

Would you like to give STAC permission to share your name and/or cancer story?*

When STAC is allowed to share our work with the community, it helps spread the word about our cause and furthers our impact. In order to use your name and other information in our public outreach, we need your permission (please agree to the STAC Publicity Agreement below)!

I'd like to give STAC permission to share my name only.

I'd like to give STAC permission to share my name and photo only.

I'd like to give STAC permission to share my name, photo, and cancer story.

I do NOT give STAC permission to share any of my information publicly.

Would you like to share your cancer story with STAC?*

On the Students Together Against Cancer website, we share - with permission - the cancer stories not just of the individuals we donate to, but of anyone in the community who wishes to contribute.

I would like to share "My Cancer Story" with STAC.

I prefer not to share my cancer story with STAC.

STAC Publicity Agreement & Release Agreement*

I (the applicant) give STUDENTS TOGETHER AGAINST CANCER (“STAC”) permission to use my name, likeness, image, and/or appearance as such may be embodied in any pictures, photos, digital images, and the like, taken or made on behalf of STAC or the STAC activities. I agree that STAC has complete ownership of such materials, including the entire copyright, and may use them for any purpose consistent with STAC’s missions. These uses include, but are not limited to illustrations, bulletins, web pages, reprints, reproductions, publications, new releases, and any fundraising or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation for the use of such materials and hereby release STAC and its agents and assigns from any and all claims which arise out of or are in any way connected with such use. I also understand that I may at any time terminate this consent and release by giving STAC written notice of termination. I understand though that any termination will not terminate any rights to the use embodied any then existing materials. I have read and understood this consent and release.

I agree.

Optional: Photo of Applicant

If you'd like to share a photo (or photos) of yourself (or the applicant), please click "Choose File" below to send one (or more) with your application. STAC will only share this photo publicly with your permission.

Drop files here or

Max. file size: 300 MB.

My Cancer Story*

In the space provided below, please describe your experience with cancer either as a patient, family member, or friend. Be as brief or in-depth as desired. We appreciate your contribution to the STAC community!

Phone

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