The BTB Foundation
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Application for
Financial
Assistance

2021 Application for Financial Assistance


The BTB Foundation is a non-profit 501(c)(3) tax exempt organization that provides financial assistance to cancer patients and their families.

The BTB Foundation will make a selection of cancer patients from the Chicago area that display financial need and that meet the BTB Foundation selection requirements to receive a financial award based on the applications submitted on time (before cutoff date of Tuesday 07/15/21) and with all required information.

The number of financial grants that The BTB Foundation can award is based on the amount of annual income raised by The BTB Foundation.  General support and involvement of all participants and their families and friends is critical in the success of the annual BTB Foundation's outing.

The information entered on this application will be reviewed by The BTB Foundation and the Beat Tom and Bill Charity Golf Outing Committee.  All information is strictly confidential and is for The BTB Foundation and the Beat Tom and Bill Charity Golf Outing Committee use only.

Please complete all required sections and provide as much detail whenever possible. We also ask that you provide the supporting reference letters and your statement of diagnosis before the December 31st deadline so that we can review all relevant information
as we evaluate your application (incomplete applications/applications without the requested reference letters and statement of diagnosis will not be reviewed until all requested documents are provided.)

If you have any questions or if you need any assistance while completing this application, please contact Bill Latourette at 847.830.1907 or email us at: assistance@btbfoundation.org.

Applicant Information

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    Guardian Information (if applicant is a minor)


    What is a Champion?

    A Champion is The BTB Foundation's main point of contact and will be the liaison between The BTB Foundation and the applicant.  The Champion can be a close friend, family member (other than the husband/wife or mother/father of the applicant) or any person that is close to the applicant. The success of The BTB Foundation's outing and our ability to provide assistance to the applicant is dependent upon the applicant selecting a Champion that is dedicated to assisting the The BTB Foundation during the planning stages or our event.

         The BTB Foundation will reply on the Champion to:
    • Provide pictures and information about the applicant
    • Answer questions The BTB Foundation may have about the applicant
    • Keep The BTB Foundation informed about the applicants medical condition
    • Keep the applicant and his/her family and friends informed about The BTB Foundation's 2021 Golf Outing and Celebration Dinner
    • Actively promote The BTB Foundation and the 2021 BTB Golf Outing and Celebration Dinner to the applicants family and friends
    • Attend all Champion meetings (4-5 meetings to discuss/plan the 2021 outing - meeting dates and times to be provided)

    Medical Information

    You understand that Congress passed a law entitled the Health Insurance Portability and Accountability Act (HIPAA) that limits use, disclosure or release of my individually identifiable health information, as HIPAA and the supporting Regulations define that phrase. I am signing this authorization because it is crucial that my health care providers release, or disclose my protected medical informattion to BTB Foundation  and its directors and members, for the sole purpose of obtaining a statement of diagnosis from my treating physician for the purposes of this application for financial assistance.

    With regard to information disclosed under this authorization, you waive any right of privacy that you may have under the aurhority of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA), any amendment or successor to that Act, or any similar state or federal act, rule, or regulation. In addition, you release any covered entity that acts in reliance on this authorization from any liability that may accrue from the use or disclosure of your individually identifiable health information in reliance upon this authorization and for any actions taken by The BTB Foundation.

    Statement of Diagnosis

    A statement of diagnosis provided by your physician is required before The BTB Foundation can complete the review of your application.  Please submit the Statement of Diagnosis to The BTB Foundation by:​
    • Email to assistance@btbfoundation.org
    • Fax # 224-267-0788
    • Mail to: BTB Foundation, 820 W. Dresser Drive, Mt. Prospect IL 60056



    Note: Under the Health Insurance Portability and Accountability Act (HIPAA) you are required to provide an authorization and release for The BTB Foundation to obtain the statement of diagnosis.  Your completing and submitting this application provides The BTB Foundation with the HIPAA Authorization and Release requirements. 

    Financial Information


    Additional Information

    Sharing names and email addresses of family and
    friends with The BTB Foundation


    Submitting a Completed Application


    In order for The BTB Foundation to review your application, the following must be completed and submitted before the Thursday 7/15/2021 deadline.  Failure to provide all the required information below may delay or forfeit any consideration from the foundation:
    • (1) Electronically sign this application
    • (2) Compete all required fields and click on the 'submit' button (below)
    • (3) Submit a Statement of Diagnosis from your doctor
    • (4) Provide two to three reference letters from family and/or friends describing why the BTB Foundation should consider your request.  
    The Statement of Diagnosis and the reference letters can be sent to The BTB Foundation via:
    • Email to: assistance@btbfoundation.org
    • Fax # 224-267-0788
    • Mail to: BTB Foundation, 820 Dresser Drive, Mt. Prospect, IL 60056

    Background Check

    In order to protect you and The BTB Foundation from fraud, we require that a criminal background investigation be administered. This does not include a credit report or a credit history. The criminal background investigation is at no cost to you and is the responsibility of The BTB Foundation. All information obtained, if any, during the criminal background investigation will be provided to you. BTB Foundation will hold the information confidential and will not release the information to any third parties. We are required to obtain authorization from you to complete this criminal background investigation.

    By electronically signing this application below, you are hereby consenting/authorizing the BTB Foundation to complete a background check of the applicant / applicant's guardian.

    Electronic Signature

Submit

  • Home Page
  • Mission
    • Larry's Page
    • Carrie's Page
    • Carmen's Page
    • Nina's Page
    • Bert's Page
    • Vincent J. Vittore Memorial Scholarship >
      • Vincent J. Vittore Memorial Scholarship Honorees
    • Sally's Studio Page
  • History
    • Who we helped 2020 >
      • Trey's Page
      • Laura's Page
      • Meg's Page
      • Austin's Page
      • Bryan's Page
      • Robert's Page
      • Ed's Page
      • Tricia's Page
      • Patricia's Page
      • Nadezhda's Page
      • Maryann's Page
    • Who we helped 2019 >
      • Donna's Page
      • Christina's Page
      • Jo Ann's Page
      • John's Page
      • Katie's Page
      • MIchelle's Page
      • Rachael's Page
      • Robert's Page
      • Rob Hyman's Page
      • Laura's Page
      • Melanie's Page
    • Who we helped 2018 >
      • Amanda's Page
      • Adriene's Page
      • Briana's Page
      • Chris's Page
      • Dave's Page
      • Lisa's Page
      • Paddy's Page
      • Mark's Page
      • Frank's Page
      • Lilia 's Page
      • Kevin's Page
      • Heart & Soul Fund - Katie Flannigan
      • Heart & Soul Fund - Megan Pedersen
    • Who we helped 2017 >
      • Greg's Page
      • Matthew's Page
      • Julie's Page
      • Steve's Page
      • Jessica's Page
      • Sharon's Page
      • Matt & Patty's Page
      • Lisa's Page
      • Karl's Page
      • Tracy's Page
      • Vivian's Page
      • Heart & Soul Fund - Abby Greene
      • Heart & Soul Fund - Travis Walters
    • Who we helped 2016 >
      • Mathias's Page
      • Jennifer's Page
      • Caleb's Page
      • Beckett's Page
      • Mataio's Page
      • Cathy's Page
      • Maria's Page
      • Lucas's Page
      • Matt's Page
      • Summer's Page
    • Who we helped - 2015 >
      • Jeff's Page
      • Steve's Page
      • Haley's Page
      • Mia's Page
      • Sophia the Brave's Page
      • Maria's Page
      • Noreen's Page
      • Nanette's Page
      • Kathleen's Page
    • Who we helped 2014
    • Who we helped 2013 >
      • Rosie's Page
    • Who we helped 2012
    • Who We Helped In 2011
    • Who We Helped in 2010
    • Who We Helped in 2009
    • Who We Helped in 2008
    • Board Members
  • Sponsor / Donate
  • Volunteer
  • News
  • Fun
    • Tom's Songs and Videos
    • Not Betting Against My Cubs Lyrics
  • Contact
  • Tom's Books
  • 2023 Scholarship Application