WHIP Cares | Team W.H.I.P.

top of page

Team W.H.I.P

(Working to Help those In Pink)

DONATE

2025 Finance Report

Home
2026 Walk
About WHIP
What We Do
Resources
Shop
Events
Podcasts
Contact
Nutrition Counseling

Let Us Help

WHIP Cares for YOU

Allow Team WHIP to be a NOW resource.

Simply complete the form below and submit. Our Cares Coordinator will be in contact. If you do not have an email address or need assistance with completing the form, please call 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 * Required

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!

Team W.H.I.P.

Stay Connected to WHIP

Team WHIP is a registered non-profit public 501(c)3 tax exempt organization serving the Chambers & Lee Counties in Alabama, and West Point of Troup and Harris Counties of Georgia

Email: info@teamwhip2015.com

Phone: 334.333.9405

Registered Public Charity: Team WHIP

EIN. 47-5501256

Subscribe to WHIP

Thanks for submitting!

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.

bottom of page