Become a Recipient : Sponsorships & Support : Pink Bandana, Inc.

Become Our Next Mud Volleyball Recipient

Now Taking Recipient Applications for the 2024 Beat Breast Cancer Mud Volleyball Tournament

Each year we choose recipients to receive the funds from the mud volleyball tournament. In order to be considered we need you to fill out the application with as much information as possible. We will not share any information you give us with anyone without your consent.

In order to be considered you must meet the following criteria:

40 years old or under
Resident of Nebraska
Have been diagnosed with breast cancer within 24 months of the application due date

Recipient Application

DEADLINE: 12/31/23

Name

First Name *

Last Name *

Date of Birth

Age

Hometown

Phone Number

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Address

Country

Address Line 1 *

Address Line 2

Address Line 3

City *

State/Province *

Postal Code *

What stage and grade is your cancer?

What types of treatments and/or surgeries are/did you receive? (Please list chronologically, including date of original diagnosis and dates of all treatments and/or surgeries)

Is this the first type of cancer you have had? If no, please describe your other cancer.

Where are you receiving treatment?

Have you been tested for the BRCA gene? (If so, please include results)

Has anyone else in your family had cancer? If so, explain their relationship to you and summarize their fight against cancer.

Who is your doctor? (If chosen, recipient will be required to complete a HIPAA release.)

Do you have insurance coverage for your treatments? If yes, what is your individual or family deductible?

Have you had any fundraisers to help you financially since you were diagnosed? Are any planned? Please provide details.

Tell us about your current working and financial situation. Where do you work? Has your job been affected since the diagnosis?

Tell us about your family.

Describe your personal support system.

Why would you be a good choice as one of our recipients?

Tell us about your passions, hobbies and anything else that would help us get to know you.

How did you hear about Pink Bandana, Inc.?