KIDS AND CANCER BENEFIT RUN

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: