“Hand in Hand” Program Application

Thank you for your interest in the Pink Perseverance “Hand in Hand” Program. Please take the time to
thoroughly read the information in this application form before filling it out.

Purpose: The Pink Perseverance “Hand In Hand” Program was developed to assist women who are currently going through breast cancer treatment and/or are breast cancer survivors, with their healthcare co-pays to purchase pre/post surgery items such as prosthesis, bras, wigs, and other garments and services through designated facilities that offer these services.

Eligibility: To be eligible for the “Hand in Hand” Program, the individual applying must be a Breast Cancer patient and/or Breast Cancer survivor that has received medical treatment related to the disease. Please include the following items with your application:
• A letter from your oncologist/physician verifying that the Applicant is a Breast Cancer patient and/or
former patient in remission. Please include contact information of the physician (telephone, email,
address, etc.)
• Include or attach a copy of the designated facility’s invoice and listed prices and items you would like to purchase from the facility.

Application Approval: Upon approval of your application from Pink Perseverance, Inc., funds will be
dispersed to the designated facility based upon the information in your application and the availability of funds. Reimbursement will only occur upon receiving an invoice from the facility for any of the suggested items listed above. Please contact Pink Perseverance at (757) 218-5176 for information on the designated facilities that have agreements with Pink Perseverance regarding this program. Your submission must include the signed “Hand in Hand” Application, Statement of Understanding, and Agreement/Release of Liability forms in
order to be processed.