ࡱ> >@= bjbj 8&784E@alv|@_aaaaaaa-222aZZZ2X_Z2_ZZs`dK0d ld d h22Z22222aaZ2222222d 222222222 : Contact Information NAME  FORMTEXT       HOME ADDRESS  FORMTEXT       CITY/STATE/ZIP CODE  FORMTEXT       DOB  FORMTEXT       HOME PHONE  FORMTEXT       CELL PHONE  FORMTEXT       EMAIL ADDRESS #1  FORMTEXT       EMAIL ADDRESS #2  FORMTEXT       Medical Contact Information DOCTOR S NAME FORMTEXT       HOSPITAL  FORMTEXT       CITY/STATE/ZIP  FORMTEXT       PRIMARY DIAGNOSIS  FORMTEXT       WORK PHONE  FORMTEXT       WORK FAX  FORMTEXT       WORK EMAIL  FORMTEXT       WEBSITE  FORMTEXT       Note: Please let your doctor know that you applied for this award because we will contact him/her to confirm your diagnosis in order to prevent fraudulent applications. The amount requested:&*246JLNXZh     ( * , @ B D X Z \ f h ﰨxjh]{Uh]{jh]oUjhY<UmHnHuj\hY<UjhY<UhY<jh]oUjth]oUjh]oUmHnHujh]oUjh]oUh]oh h>*CJ h>*-(*j, @ B z | >  dhgd5Hdhdhgd]{  dh]  dh] gdY< & dh] ~dh]~ dh] ]   . 0 2 < > @ B P x |   , ҵұ챦ڱΆҵڑ{ҵڑsjh5HUjh]oUjh]oUh5H h>*CJ h>* h5H>*j,h]{Uh]{jh]oUmHnHujh]oUh]ojh]oUhjh]{UmHnHujh]{UjDh]{U+, . 0 : < ` b d x z |     2 4 6 @ B F X Z n p r | ~ : εα֦εֱ֛εα֐εֱօεαzh5Hh5HCJaJjh]oUjfh]oUjh]oUjzh]oUhjh]oUmHnHujh]oUjh]oUh]oh5Hjh5HUmHnHujh5HUjh5HU,: .024HJLVX\|ɾͰɫyskg\kj>hJ UhJ jhJ U hJ CJ h]{h]{jh]{UmHnHujh]{Uh]{jh]{U h]{CJ h]{>*jh{RUmHnHujRh{RUh{Rjh{RU hCJ hJ hJ U hJ >*h]oh]{h]oCJaJh5HCJaJ" (between $100  $1000)  FORMTEXT       Please describe why you deserve this award. We are looking for HCC patients who are advocates for themselves during their fight against liver cancer. Do not write beyond one page.  FORMTEXT       Please explain how you intend to use the funds (e.g., food, clothing, shelter, treatment, entertainment). We appreciate specificity so be as descriptive as possible; however, do not write beyond one page.  FORMTEXT       I certify that the above information is true and correct. I understand that I could be subject to legal action should the above information prove to be false.  FORMTEXT       Print name Signature Date     Adrienne Wilson Spirit Award Application 02\^.&d 7$8$H$P gd9 7$8$H$gd9dhgd]odhgd]{gd]{gdJ dhgd{R *,.J^h|õén`n`nXTXTXTXTPh5HhFjhFUh9CJOJQJ^JaJ h9h9CJOJQJ^JaJ h9>*jh:UmHnHujh:Uh:jh:Uh9h9>*CJaJh UCJOJQJ^JaJ h9h9CJOJQJ^JaJh]{CJOJQJ^JaJh{RhJ jhJ UjhJ UmHnHu 7$8$H$gd9$a$  h9h9CJOJQJ^JaJhFh6&P1h:p9/ =!"#$% tDText1tDText3tDText4tDText2tDText5tDText7tDText9vDText10vDText11vDText12vDText14vDText13vDText15vDText16vDText17vDText18vDText19vDText19vDText19vDText19^ 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~_HmH nH sH tH H`H Normal CJOJQJ_HaJmH sH tH RR  Heading 1$<@&5CJ KH \^JaJ DA D Default Paragraph FontViV 0 Table Normal :V 44 la (k ( 0No List :0:  List Bullet  & F4@4 Header  !4 4 Footer  !PK![Content_Types].xmlj0Eжr(΢Iw},-j4 wP-t#bΙ{UTU^hd}㨫)*1P' ^W0)T9<l#$yi};~@(Hu* Dנz/0ǰ $ X3aZ,D0j~3߶b~i>3\`?/[G\!-Rk.sԻ..a濭?PK!֧6 _rels/.relsj0 }Q%v/C/}(h"O = C?hv=Ʌ%[xp{۵_Pѣ<1H0ORBdJE4b$q_6LR7`0̞O,En7Lib/SeеPK!kytheme/theme/themeManager.xml M @}w7c(EbˮCAǠҟ7՛K Y, e.|,H,lxɴIsQ}#Ր ֵ+!,^$j=GW)E+& 8PK!Ptheme/theme/theme1.xmlYOo6w toc'vuر-MniP@I}úama[إ4:lЯGRX^6؊>$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3ڗP 1Pm \\9Mؓ2aD];Yt\[x]}Wr|]g- eW )6-rCSj id DЇAΜIqbJ#x꺃 6k#ASh&ʌt(Q%p%m&]caSl=X\P1Mh9MVdDAaVB[݈fJíP|8 քAV^f Hn- "d>znNJ ة>b&2vKyϼD:,AGm\nziÙ.uχYC6OMf3or$5NHT[XF64T,ќM0E)`#5XY`פ;%1U٥m;R>QD DcpU'&LE/pm%]8firS4d 7y\`JnίI R3U~7+׸#m qBiDi*L69mY&iHE=(K&N!V.KeLDĕ{D vEꦚdeNƟe(MN9ߜR6&3(a/DUz<{ˊYȳV)9Z[4^n5!J?Q3eBoCM m<.vpIYfZY_p[=al-Y}Nc͙ŋ4vfavl'SA8|*u{-ߟ0%M07%<ҍPK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 +_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!Ptheme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  & 666669 , :   &,BNTjv| KW]htz ,8>%+FFFFFFFFFFFFFFFFFFFF8@0(  B S  ?Text1Text3Text4Text2Text5Text7Text9Text10Text11Text12Text13Text15Text16Text17Text18Ck Li, -U}^{!?3-BUj} (>^_gh{|!,?@.\HC hh^h`OJQJo(tJ G*9:Y<F5H|M{R U>zW]o]{ }Fg@(`` `UnknownG*Ax Times New Roman5Symbol3. *Cx ArialG TimesNewRomanMSA BCambria Math"1h3F  O!x0d2QHP $PF*!xxPersonal Contact InformationAndrea Wilson WoodsAndrea Wilson Woods Oh+'0  0 < H T`hpx Personal Contact InformationAndrea Wilson WoodsAWSA applicationAndrea Wilson Woods1Microsoft Office Word@F#@Dc@L`@ZTp`՜.+,0 hp  Sony Electronics, Inc.  Personal Contact Information Title  !"#$%&'()*+,./012346789:;<?Root Entry F࠻s`AData 1Tablet WordDocument8&SummaryInformation(-DocumentSummaryInformation85CompObjy  F'Microsoft Office Word 97-2003 Document MSWordDocWord.Document.89q