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.

Requirements:

Child must be currently diagnosed with cancer or relapsed in the last 24 months.
Child must be 18 years or younger.
Pediatric Physician, Hematologist, and/or Oncologist signature is required.

Voices Against Cancer can provide gift cards for gas, groceries, medical items not covered by insurance, and home rent or mortgage payments as well as utilities (Copies of statements are required). 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 at (info@voicesagainstcancer.org) 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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Patient Name

Patient D.O.B.

Parent/Guardian Name 1:

Parent/Guardian Name 2:

Current Address

Address Line 1

Address Line 2

City

State

Zip Code

Best Phone Number

Receiving Treatment at:

(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)

Assistance Need #1

Assistance Need #2

Assistance Need #3

Have you applied for, or received financial assistance, from Voices Against Cancer before?

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.

Signature

Clear Signature

Date / Time

Relationship to Patient:

Complete Physician Information Form Online:

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Physician/Hematologist/Oncologist

Name

Hospital/Clinic/Facility or Practice Name

Address

Address Line 1

Address Line 2

City

State

Zip Code

Phone

Patient Name

Patient Diagnosis

Is this child currently (within the last 12 months) under your care?