TYF Support Application

Section 1: Applicant / Patient Details

Gender
MaleFemalePrefer not to say

Section 2: How Did You Find TYF Foundation?

Self-application via websiteHospital / clinic referralCommunity health worker referralFamily / friend recommendationOther

Section 3: Medical Information

Must be supported by a medical letter or referral.

[radio* cancer-status default:1 “Confirmed cancer diagnosis” “Suspected cancer (awaiting diagnosis / testing)”]

Section 4: Type of Support Requested

Cancer Diagnosis and TestingPalliative Care SupportTransportation SupportPsychosocial / Counselling Support

Note: TYF Foundation currently funds cancer diagnosis and testing, palliative care, transportation, and psychosocial support. Funding for chemotherapy, radiotherapy, and surgery is not yet available.

Section 5: Financial Situation

All information is treated in strict confidence.

[radio* employment-status default:1 “Employed (formal)” “Employed (informal / self-employed)” “Unemployed” “Student” “Retired” “Unable to work due to illness”]

[radio* health-insurance default:1 “Yes (NHIS)” “Yes (Private Insurance)” “Yes (Employer-based)” “No health insurance”]

Section 6: Supporting Documents

Tick each document you are attaching / will send:

Medical letter / referral from a licensed doctorProof of identity (National ID / Voter's Card / Passport / Birth Certificate)Proof of address (utility bill, tenancy agreement, or LGA letter)Financial statement or sworn affidavit of income / financial statusItemised cost estimate from hospital, diagnostic centre, or clinicReferral letter from hospital / health worker (if applicable)

Section 7: Declaration and Consent

I confirm the information provided is true and accurate. I understand that false information will result in disqualification. I give TYF Foundation permission to verify the information with my doctor or hospital. I consent to TYF Foundation holding and processing my personal and medical information in accordance with applicable Nigerian data protection law. I understand that submitting this form does not guarantee approval.

[acceptance* declaration] I agree to the above declaration and consent.