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Team W.H.I.P

(Working to Help those In Pink)

2025 Finance Report

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Let Us Help

WHIP se preocupa por TI

Permita que Team WHIP sea un recurso.

Simplemente complete y envíe el formulario a continuación y nuestro Coordinador de Cuidados se pondrá en contacto con usted. Si no tiene una dirección de correo electrónico o necesita ayuda para completar el formulario, llame al 334-333-9405.

TODAYS DATE * required

Enter your LEGAL Name as it appears on your Government Issued ID

First Name

Middle

Last Name

Phone

Email

Patient Status

Date of Diagnosis * required

Treating Provider

Diagnosis/Treatment Summary

Verification Diagnosis Document

Upload File

Upload supported file (Max 15MB)

Requested Assistance. Check All that Apply * Obligatorio

Transportation

Medication

Co-pay

Groceries

Employment Status

Gender at Birth *

Female

Male

Ethnicity *

Black/African

White/Caucasian

Hispanic/Latino

Asian

Other

Age at the time of diagnosis *

Ages 18 - 25

Ages 26 - 39

Age 40 - 55

Ages 56 - 69

Age 70+

Street Address

City

Postal / Zip code

Bldg, Apt, Unit #

State

Country

I affirm that the information I have provided in this application is true, complete, and accurate to the best of my knowledge. I understand that submitting false or misleading information may result in denial of assistance.

I authorize the organization to contact me if additional documentation is needed.

I understand that all information submitted is confidential and will be used for internal program purposes. No information will be disclosed to third parties.

Your Signature

Please submit only one form.

Thanks for submitting!

Equipo WHIP

Stay Connected to WHIP

Team WHIP es una organización pública 501(c)3 sin fines de lucro registrada y exenta de impuestos que presta servicios en los condados de Chambers y Lee en Alabama, y en los condados de West Point de Troup y Harris en Georgia.

Correo electrónico : info@teamwhip2015.com

Teléfono : 334.333.9405

Organización benéfica pública registrada: Team WHIP

EIN. 47-5501256

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Team WHIP embrace and encourage our differences in age, color, ethnicity, gender identity, physical and mental ability, race, religion, socioeconomic status. We are committed to cultivating and preserving a culture of diversity, equity, and inclusion.

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