Request Aid - Kids and Cancer Benefit Run

Request Financial Aid from Kids and Cancer Benefit Run

A grant request form is available here. You can download it, fill it out, and mail it to us. Note that Adobe PDF Reader is required. Get the latest version of the Adobe Reader here.

Or, if you prefer, you can fill out the form below and it will be emailed to us. We will contact you shortly. You can upload up to 3 documents in image format or pdf.

KIDS AND CANCER ORGANIZATION

Donation Request Application

Patient Information

(All fields required)

Full Name:

Date of Birth:

Address:

City, State, Zip:

E-mail:

Official Diagnosis:

Description of Illness (or injury):

Contact Information

(If different from Patient Information)

Full Name:

E-mail:

Address:

City, State, Zip:

Phone#:(land/cell):

Request for Assistance

Please indicate if you have a preference where you would need assistance:
Co-pay not covered by insurance (submit a copy of the unpaid bill with application)Payment towards a doctor visit or treatment facility (submit a copy of the unpaid bill with application)Medicine/Pharmacy (submit a copy of the unpaid bill with application)Gas card to assist with travel expenses for medical appointmentsOther* (please describe request in detail and submit a copy of the unpaid bill with application)

* This can be an unpaid home utility bill, a mortgage payment, rent payment, etc.
Upload up to 3 documents if required:

I am submitting this application on behalf of who has been diagnosed as stated above and requires assistance with the costs associated with treatment. I agree that by submitting and signing this request that all information contained herein is accurate and true to the best of my knowledge.

Name of Adult Patient:
Name of Requestor (if a minor):
Date:

Publicity Release

Kids & Cancer organization, with the help of many volunteers and donors, is honored to be able to assist families facing financial hardships due to pediatric cancer and other life-threatening illnesses. We respectfully request the usage of your name and/or photo in releases such as Facebook, newsprint, and/or at our public events. This is not mandatory.
I give permission to the Kids & Cancer organization to use my name and photo for media recognition.I DO NOT give permission to Kids & Cancer organization to use my name or photo for any media purpose.
Name of Adult Patient:
Name of Requestor (if a minor):
Date:

Thank you for your support!