Financial Assistance Application

Applicants must:

*Have had a diagnosis of breast cancer.

*Be (or become) a member of BCAK to be eligible to apply. The membership fee is $30/year, and a receipt will be issued.

Breast Cancer Action Kingston offers financial support to those individuals residing in or receiving their treatment within the South East LHIN.

Are you a member of BCAK?
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If paying $30 at time of submitting application, please click Membership Form below

Verified diagnosis of Breast Cancer:
Do you and/or your spouse/partner have a benefit plan to assist with costs?
Have you applied to other agencies to assist with costs?
What is your current employment status?

Financial Cap: Up to $1,000 per year including any items below.  Total maximum allowance per person of $2,000.

  • Prosthesis - $150 every 2 years

  • Partial Prosthesis - $50 every 2 years

  • Wigs - $250 every 2 years

  • Bras (maximum 2) - 50% every 2 years

Please check the reason(s) for financial assistance and attach any relevant documentation and/or proof of purchase receipts.  Missing information may cause a delay in processing the application.

Applicant's requirement for funds:
Upload Supporting Documentation

Thank you for your submission.

AMOUNT APPROVED: __________________                       DATE: ___________________________

 

SIGNATURE: __________________________________________                         PAYABLE TO: _____________________