Apply for Assistance - Save The Cups

Nominate Someone

Personal Information

Your Name

Your Phone

Your Email

Your Age

Where do you live, City and State?

Medical Information

When were you diagnosed with breast cancer?

Is this your first occurrence? Has it metastasized?

What is your official diagnosis? Please include Stage

Where are you in the treatment process?

Have you had any recent hospitalizations? Please provide date

Your Journey

Who or what has been your support on your journey with breast cancer?

How much do you have in outstanding medical bills related to your treatment?

Do you have medical insurance?

What is your out of pocket maximum?

Additional Information

How did you hear about Save the Cups?

Have you been to a Swig location? If so, which locations?

Is there anything else you would like to share?

Upload photos or videos

Click to upload or drag and drop

At least one photo or video is required

image/jpeg, image/png, image/webp, video/mp4, video/quicktime up to 25 MB (max 5 files)

Legal Disclosure: By submitting this form, you confirm the information provided is accurate and consent to its use by Swig for the sole purpose of administering the Save the Cups program. If nominating someone else, you represent that you have their permission to share their personal and medical information. Submission does not guarantee assistance.