Family Assistance Application

Going through cancer is difficult at any age for any person, but when it is your own child, it is even that more difficult.  Children should be playing and going to school, not getting needle pokes and hospital stays.  Voices Against Cancer is here to try to lessen the burden by helping to provide financial assistance whenever possible.


  • Child must be currently diagnosed with cancer or relapsed in the last 12 months.
  • Child must be 18 years or younger.
  • Child must be living with parents/guardians in the South Dakota, North Dakota, Minnesota, Iowa, or Nebraska region at time of diagnosis.
  • Pediatric Physician, Hematologist, and/or Oncologist signature is required.

At the current time, Voices Against Cancer can only provide gift cards for gas, groceries, and lodging.  Please be advised that we will make every effort to assist you, however submitting an application does not guarantee funds will be available to assist you.

Application Instructions

Families can complete this form below, or – you can download the file and send it to us via email ( or mail to 47891 Prairie Circle, Harrisburg, SD 57032. Please give your physician the Request for Physician Information form to complete. Both forms must be received by us to review your application.

Complete Patient Information Form Online:

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Current Address
(Location of treatment has no effect on determination of assistance)

Please rank from greatest need to least need your preference for assistance (gas, groceries, lodging)

I certify that to the best of my knowledge the information listed above is accurate and complete. I hereby give permission for applicant’s personal and medical information to be shared with Voices Against Cancer pursuant to this request only for financial and referral assistance.

Clear Signature